Case Report: Epidural anaesthesia in a patient with spina bifida and difficult airway.

Abstract

Introduction: This case report outlines a 38 week gestation, multigravida woman scheduled for elective caesarean section, with a history of spina bifida, associated neurological deficit, and a history of difficult intubation during her previous caesarean. This case describes successful anaesthesia for subsequent elective Caesarian section using an epidural technique with no associated complications. Case report: 36-year-old woman, G3P2, whose obstetric history included two prior emergency caesarean sections for IUGR and major placenta praevia. During her second caesarean, difficulty was encountered during intubation, where anaesthetists were able to obtain a view using the CMAC D-blade but difficulty feeding the endotracheal tube. She was seen at a tertiary hospital obstetric anaesthesia high risk clinic and both general anaesthesia (GA) and epidural options discussed. An MRI of her lumbosacral spine showed a low tethered cord, with the lowest margin of the cord at the mid-S2 level. On the day of surgery an epidural technique was agreed upon by the patient and anaesthetic team, after informed consent was obtained. After preparing the patient's back with antiseptic wash, and local anaesthesia was applied to skin, an 18gauge Touhy needle was used to locate the epidural space using a loss of resistance to saline technique. After single pass, the space was located at 5.5cm, and the catheter fed and secured. After negative aspiration of cerebrospinal fluid or blood was confirmed, a test dose of 0.2% Ropivacaine was injected via an epidural filter. Further increments of 5mL of 0.2% Ropivacaine + 2mcg/mL Fentanyl was used until adequate block was obtained to the T4 dermatome. A total of 15mL of solution provided adequate anaesthesia. Surgery was completed with no associated complications. Discussion(s): Spina bifida occulta is the most common neural tube defect, with an incidence of roughly 20%, and often is an incidental finding. Features of the disease that can impact our choice of anaesthetic include low lying spinal cord and tethered spinal cord, and therefore a spinal technique may not be suitable. An epidural technique in this patient population is also potentially problematic. There is a higher risk of failure, dural puncture, post-dural puncture headache, and inadequate or unpredictable spread of injected drugs, neurological injury, or haematoma. The risks versus benefit of epidural technique were carefully weighed against airway difficulty for this patient. Conclusion(s): An epidural technique is potentially a suitable technique in a parturient with spina bifida occulta, and mitigates the need for airway intervention.