Pregnancy with syringomyelia

[sigrhoillusion]

G1Po presenting for induction of labor. Supposed hx of syringomyelia, but NO records. Had hx of situs inversus and MULTIPLE bowel surgeries (x5-6) so OBs are hesitant to cut her open.

Patient not the best historian but denies symptoms. Trying to get old records but nothing at this time.

Looking through case reports... Thoughts?

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[Orin]

Should totally drop a catheter into the syrinx and write that up...

 

[Noyac]

Where is the syrinx located?
If she is symptom free after a good neuro exam I would probably proceed. Any past MRI studies?

 

[sigrhoillusion]

That's the issue... she's not sure where it's located. She had a workup many years ago, and is in the process of getting records. She thinks mid to lower back...

She's symptom free, but again, I'd prefer to know where this thing is before I put a needle in her back. Also, after talking to her she only had ONE abdominal surgery and since then has had several episodes of obstruction which were relieved non-operatively with fluids and pain meds.

She's just being induced tonight so probably won't be an issue until tomorrow morning when colleague comes along. She wants to go natural and does NOT want an epidural (that's what they all say...). I told her my plan, since I didn't know anything about the syrinx/syringomyelia was that since she's asymptomatic (now) that if she goes natural and the pain is really bad and/or she has any neurological issues (since I guess the concerns are about increased ICP) that we can control her pain with a PCA. If for some reason we have to section her, I would prefer to do GA. That being said, I told her that my colleague may have completely different feelings, and he might be willing to do regional if she wants it at the time. But I personally would do PCA and GA with the limited info we have.

It seems like every other case report I've read about these things has a different opinion. And I'm sure that tons of epidurals/spinals have been placed on patient's with an unknown syrinx with no issues. A lot of them are found incidentally. She had fractured a vertebra in the past which is how they found the syrinx in the first place, but again she's not 100% sure where it is.

 

[dhb]

[QUOTE="sigrhoillusion, post: 18271243, ]Had hx of situs inversus and MULTIPLE bowel surgeries (x5-6) so OBs are hesitant to cut her open. [/QUOTE]

What does that have anything to do with a c-section OB...

 

[sigrhoillusion]

Seriously... i think it's more that they would have preferred since then they'd take forever. But how that would affect a c-section not sure since the uterus has been untouched. Guess they are worried about adhesions leading to 7 hr section... aka spinal wearing off. These OBs are slow enough as is with regular sections.

[QUOTE="sigrhoillusion, post: 18271243, ]Had hx of situs inversus and MULTIPLE bowel surgeries (x5-6) so OBs are hesitant to cut her open.

What does that have anything to do with a c-section OB...[/QUOTE]

 

[Planktonmd]

We had a very good thread about this a while back:
http://forums.studentdoctor.net/threads/chiari-i-malformation.480487/#post-6003672

 

[deleted59964]

get the notes, or get an mri

 

[urge]

Pent sux tube

 

[Noyac]

Sounds like a good indication for a remi PCA if your facility uses these.

 

[sigrhoillusion]

Sounds like a good indication for a remi PCA if your facility uses these.

I could probably set one up, but i doubt it's in there order sets. i was thinking the same thing. What do you usually set yours at?

And anything new here is looked at like witchcraft. I started giving ketamine to people in the OR here and people liked at me like I was performing voodoo. Little do they know, but half the stuff we do is voodoo... at least that's what I tell the med students and surgical residents ...

 

[Noyac]

I could probably set one up, but i doubt it's in there order sets. i was thinking the same thing. What do you usually set yours at? ...

We don't use it.
Mostly because the only time I ever want to use it is in situations like this and I haven't bothered to bring the staff up to speed with it.

 

[deleted162650]

I set up one remi PCA for labor in residency on a pt that had a diffuse back rash that looked sorta fungusy. The pharmacist acted like I had 2 heads when I asked for it, so I ended up having to mix up a bag myself. I think I even had to jury rig the settings on an epidural pump cuz we couldn't get a real PCA pump. No basal rate. 50mcg bolus. Lockout time is tricky cuz most pumps won't let u go fast enough to be ideal for remi but 1min will work. You need to coach the pt that they need to anticipate the contraction a little bit for it to really work. I stayed in the room for the first few contractions to make sure she got the hang of it and wasn't gonna overdo it.

 

[Planktonmd]

I set up one remi PCA for labor in residency on a pt that had a diffuse back rash that looked sorta fungusy. The pharmacist acted like I had 2 heads when I asked for it, so I ended up having to mix up a bag myself. I think I even had to jury rig the settings on an epidural pump cuz we couldn't get a real PCA pump. No basal rate. 50mcg bolus. Lockout time is tricky cuz most pumps won't let u go fast enough to be ideal for remi but 1min will work. You need to coach the pt that they need to anticipate the contraction a little bit for it to really work. I stayed in the room for the first few contractions to make sure she got the hang of it and wasn't gonna overdo it.

In all honesty... any PCA concoction that your pharmacy is OK with should work, but also you could let the OB do their own thing and go home!

 

[deleted162650]

In all honesty... any PCA concoction that your pharmacy is OK with should work, but also you could let the OB do their own thing and go home!

Ya, but when you're a resident doing that kind of goofy crap is still fun. Plus, you're stuck there anyways.

 

[Hoya11]

That's the issue... she's not sure where it's located. She had a workup many years ago, and is in the process of getting records. She thinks mid to lower back...

She's symptom free, but again, I'd prefer to know where this thing is before I put a needle in her back. Also, after talking to her she only had ONE abdominal surgery and since then has had several episodes of obstruction which were relieved non-operatively with fluids and pain meds.

She's just being induced tonight so probably won't be an issue until tomorrow morning when colleague comes along. She wants to go natural and does NOT want an epidural (that's what they all say...). I told her my plan, since I didn't know anything about the syrinx/syringomyelia was that since she's asymptomatic (now) that if she goes natural and the pain is really bad and/or she has any neurological issues (since I guess the concerns are about increased ICP) that we can control her pain with a PCA. If for some reason we have to section her, I would prefer to do GA. That being said, I told her that my colleague may have completely different feelings, and he might be willing to do regional if she wants it at the time. But I personally would do PCA and GA with the limited info we have.

It seems like every other case report I've read about these things has a different opinion. And I'm sure that tons of epidurals/spinals have been placed on patient's with an unknown syrinx with no issues. A lot of them are found incidentally. She had fractured a vertebra in the past which is how they found the syrinx in the first place, but again she's not 100% sure where it is.

I agree with you I would do general also for CS. Also agree with remi PCA if needed for labor. She sounds like shes weird and prone to problems...so keep it simple.

 

[Onefellswoop87]

Where is the syrinx located?
If she is symptom free after a good neuro exam I would probably proceed. Any past MRI studies?

Could you slap an ultrasound on her lower back to make sure you are not threading an epidural through the syrinx?

The only articles in I could find were about ultrasound for syringomyelia in neonates

 

[sigrhoillusion]

Could you slap an ultrasound on her lower back to make sure you are not threading an epidural through the syrinx?

The only articles in I could find were about ultrasound for syringomyelia in neonates

I actually did grab an ultrasound but couldn't see s**t... couple vertebrate but not much more. And again, I was only looking from about T12 to L5... again had NO clue where the thing might be.

 

[Orin]

I'm confused as to what the concern here is. I blame the Laphroaig.

We're talking about an intraparenchymal spinal cord lesion and performing an epidural or a single shot spinal below the conus.

I would do a GETA due to the risk for surgical misadventure and significant bleeding due to the situs/prior surgeries, but I'm not sure what your fears are regarding neuraxial.

You could probably do something resembling a physical exam to assess for a band of neurologic abnormalities corresponding with a syrinx, but beyond that, what would happen? If you're worried about an undiagnosed chiari causing the syrinx, the epidural would still be better for ICP problems right? Again, remember or ask Dr. Google, but most of the time these are cervical lesions.

 

[sigrhoillusion]

Looking at her cjart at home just now, looks like they had neurology swing by. Neurologist of course states they would like to have imaging if available. Then of course OB puts note that says the patient can't get an epidural because of syringomyelia. Not true... not what I told them. I said that without more information I'd be hesitant to do regional. That being said, if the patient absolutely wanted one and understood the risks and alternatives then perhaps it could be considered. Problem is the patient had 9 months to prepare for this moment and chose not to do anything about it, and supposedly the OBs had asked her to get records. Not trying to place any blame on her because she was a very nice sane patient, but it's annoying when a lot of burden is put on us when we don't have all the info.

It's like the Jehovh's witnesses getting huge surgeries that when you ask them what you CAN give them they look at you like they have no idea what you are talking about. And now 10 minutes before going to the OR it's now our job to explain the multitude of other things that may be done to help with blood loss. Actually last night I was pre-oping a Jehovah's patient who actually has a blood directive in his chart which specifically marked what they would be willing to accept. I WAS FLOORED!!!

 

[narcusprince]

Question for OB if her pain is not controlled with PCA will she be ready to section the patient for pain? Agree with remi pca and GA for section. Likely this is going to section.

 

[sigrhoillusion]

I'm confused as to what the concern here is. I blame the Laphroaig.

We're talking about an intraparenchymal spinal cord lesion and performing an epidural or a single shot spinal below the conus.

I would do a GETA due to the risk for surgical misadventure and significant bleeding due to the situs/prior surgeries, but I'm not sure what your fears are regarding neuraxial.

You could probably do something resembling a physical exam to assess for a band of neurologic abnormalities corresponding with a syrinx, but beyond that, what would happen? If you're worried about an undiagnosed chiari causing the syrinx, the epidural would still be better for ICP problems right? Again, remember or ask Dr. Google, but most of the time these are cervical lesions.

I agree. I did do some literature search but for the few case reports I found I also saw literature which presented the risks. And a lot of the case reports had images meaning they were known prior and some plan had been made for the delivery. Regardless, I agree that there's probably no real threat in an asymptomatic patient with no neuro issues. The patient was very reasonable and really wanted to try to go natural (which may also have risks due to pain theoretically causing increased ICP). I think in the end it is OK to let her decide as long as she understands the risks.

But like I originally stated she was very reasonable, did not actually want an epidural so not that she was pleading for one and we were denying her, there are other options and she appeared to have a normal airway so if GA was needed I'd be comfortable putting her to sleep.

 

[dhb]

If someone can explain to me why some posters are refering to previous laparotomies to justify a possible difficult c-section i would be very enlightened.
I had this notion that the peritoneum kind of seperated both sites...

 

[Psai]

If someone can explain to me why some poster are refering to previous laparotomies to justify a possible difficult c-section i would be very enlightened.
I had this notion that the peritoneum kind of seperated both sites...

?
You think the uterus is retroperitoneal?

 

[Planktonmd]

?
You think the uterus is retroperitoneal?

The uterus is extraperitoneal my friend.

 

[Psai]

The uterus is extraperitoneal my friend.

So because it's extraperitoneal, you don't slice into the abdomen to get to the uterus? I don't understand your point my friend.

 

[Planktonmd]

So because it's extraperitoneal, you don't slice into the abdomen to get to the uterus? I don't understand your point my friend.

I didn't say you wouldn't slice anything... I was just responding to your anatomy question!

 

[Psai]

Sorry I meant like posterior like the kidneys. The original question is what made no sense to me, as though the poster had never seen a c section before. Whether or not it is covered by peritoneum is clinically irrelevant.

 

[deleted162650]

Chances are slim to none that there's bowel stuck in between a term gravid uterus and the abdominal wall. But, that's something that would be pretty damn easy to see with a bedside U/S exam. Could always get a formal abd U/S if they're really worried.

I'm also in the camp that doesn't see why we're so concerned about placing a lumbar epidural in a pt with an asymptomatic phantom syrinx that is a) intramedullary and b) distant to where I'm gonna thread my cath.

 

[dhb]

Sorry I meant like posterior like the kidneys. The original question is what made no sense to me, as though the poster had never seen a c section before. Whether or not it is covered by peritoneum is clinically irrelevant.

Well clearly it's relevant to the case

 

[dhb]

So because it's extraperitoneal, you don't slice into the abdomen to get to the uterus? I don't understand your point my friend.

So you usually do laparotomies for c-sections?

 

[Psai]

So you usually do laparotomies for c-sections?

Where do your pfannenstiels go? The chest cavity?

 

[dhb]

Oh so you are giving me anatomy lessons now? Let's rewind:

?
You think the uterus is retroperitoneal?

Prior intra-abdominal surgery has no bearing on the difficulty of a c-section. It's like saying a tibial rod would be difficult to place because of a previously fractured femur.

 

[deleted171991]

Chances are slim to none that there's bowel stuck in between a term gravid uterus and the abdominal wall. But, that's something that would be pretty damn easy to see with a bedside U/S exam. Could always get a formal abd U/S if they're really worried.

I'm also in the camp that doesn't see why we're so concerned about placing a lumbar epidural in a pt with an asymptomatic phantom syrinx that is a) intramedullary and b) distant to where I'm gonna thread my cath.

When people are concerned about pre-existing neurologic disease it's many times related to the malpractice angle. Unless one wastes one time to document the heck out of a well-done neuro exam (neither of which most anesthesiologists do), there is a risk that one can be accused of having caused more damage/symptoms. Yes, syringomyelia is mostly cervical, AFAIK, but it can also develop segmentally anywhere, possibly in the lumbar cord or even around the conus medullaris, I guess.

The idea is that it's just not worth the headache, unless it's a bad airway. It's the same logic for which we don't place regional anesthesia for limbs with pre-existing injury, or why insurance companies used to not insure for pre-existing disease.

 

[deleted162650]

Prior intra-abdominal surgery has no bearing on the difficulty of a c-section. It's like saying a tibial rod would be difficult to place because of a previously fractured femur.

While the uterus is extra-peritoneal, it is accessed through the peritoneal space. Still, the odds of prior bowel surgery making a section difficult are exceedingly small - but I'm sure academic OB's could make it happen.

 

[Psai]

Oh so you are giving me anatomy lessons now? Let's rewind:


Prior intra-abdominal surgery has no bearing on the difficulty of a c-section. It's like saying a tibial rod would be difficult to place because of a previously fractured femur.

My mistake was not clarifying between retroperitoneal vs retroperitoneal approach.

You're the guy who thinks that c-sections aren't laparotomies.

 

[dhb]

You're the guy who thinks that c-sections aren't laparotomies.

Ok i meant vertical (sub-umbilical) laparotomy