European Review for Medical and Pharmacological Sciences 2011; 15: 458-460 A 12-month follow-up for neurological complication after subarachnoid anesthesia in a parturient affected by multiple sclerosis

G. MARTUCCI, A. DI LORENZO, F. POLITO*, L. ACAMPA**

Department of Anesthesiology and Intensive Care, Second University of Naples (Italy) *Department of Obstetrics and Gynecology, and **Department of Anesthesiology, Ospedale S.S. Annunziata, Naples (Italy)

Abstract. – Multiple sclerosis is common ing areas in the brain and the spinal cord, and among women of childbearing age. Neuraxial manifests itself in periods of exacerbations and blocks have been administered to them with re- remissions. luctance because of the hypothetical risk that lo- With regard to general anesthesia we have a cal anesthetics might be more histotoxic to neural tissue already compromised by multiple rather wide experience, while there is not a unan- sclerosis. imous consensus on loco-regional anesthesia and In spite of the lack of uniform guidelines on in particular for central blocks because of lack of disorders in pregnancy like multiple sclerosis, large trials or a high number of published cases. and of the published data that sometimes con- We describe the case of a pregnant woman af- trast each other, experience gained in recent fected by MS in which we performed subarach- years has indicated that regional anesthesia is safe even in these patients, but there aren’t noid anesthesia for a cesarean section. We ana- many published cases. lyzed the aspects that literature defines as critical We describe the case of a pregnant woman af- points in patients affected by MS: the intensity, fected by multiple sclerosis in which we admin- level and duration of analgesia; whether exacer- istered spinal anesthesia for a cesarean section, bations or worsening of preoperative neurologi- and we analyzed the aspects that literature de- cal disorders appeared in the immediate period fines as critical points in this group of patients. after surgery and anesthesia. We prolonged the The results were favorable with regard to the level, intensity and duration of anesthesia. No follow-up by one year and carried out neurologic neurological exacerbations were recognized examination every three months. during the hospital stay, nor during the follow-up that lasted 12 months. Case Report A 29-year old patient at her first pregnancy in Key Words: the 39th week was admitted to the Obstetric Ward Loco-regional anesthesia, Multiple sclerosis, Spinal for a cesarean section. She had been affected for anesthesia. seven years by MS localized in the brain and the cervical spinal cord, manifested at the beginning by diplopia, weakness and paresthesias at the left up arm, treated with interferon beta and corticos- teroids. At the beginning of pregnancy, the Introduction woman had a 2,5 Expanded Disability Status Scale and interrupted any pharmacological treat- Neurological and neuromuscular diseases per- ment with an uneventful positive course of preg- sist as a critical area for anesthetists taking into nancy. account the growing concern about exacerbation At the preoperative assessment, we did not or worsening of pre-existing neurological deficits recognize other diseases or laboratory alteration after surgery and anesthesia. apart from a physiological variation during preg- Multiple sclerosis (MS) is a progressive au- nancy. The patient was 164 cm tall, weighted 72 toimmune disease characterized by demyelinat- kg and we attributed to her the risk II according

458 Corresponding Author: Gennaro Martucci, MD; e-mail: [email protected] Neurological complication after subarachnoid anesthesia in a parturient affected by MS to the ASA Classification. Considering our stan- by a growing disability over time. In Italy, MS dard management for cesarean sections and the affects more than 50,000 people, two-thirds of absence of major contraindication, we decided to these patients are women and primarily of child- perform spinal anesthesia. bearing age. Therefore, MS should be considered Obtaining the informed consent, we warned common among pregnant women. the patient that there was a remote possibility of Literature reporting the use of regional blocks a relapse of the disease after the childbirth (not in women with MS is limited and in some cases only because of the central block). conflicting. Preexisting neurological diseases still Despite that, the patient was strongly oriented represent a concern, also because of litigation is- towards regional anesthesia because of the possi- sues, therefore some anesthetists tend to prefer bility of hearing the newborn’s first cry. general anesthesia as verified in reviews like the She was monitored in the operating room one by Vercauteren and Heytens1 or the retro- with: heart rate, pulsoxymetry, ECG, non inva- spective survey by Drake et al2 although there is sive blood pressure. Prehydration with 300 ml of not any strong evidence about serious complica- colloids was performed. tion related to regional anesthesia in these pa- The patient was placed in the sitting position, tients3,4. Historically, the use of regional anesthet- the block was performed in the space between ic techniques within this patient population has the second and the third lumbar vertebrae with a been contraindicated for fear of worsening the 25 Whitacre needle through the median access neurologic outcome through the “double-crush” with one puncture and was administered 0,5% phenomenon (patients with preexisting neural hyperbaric bupivacaine (10 mg). During the 50- compromise would be more susceptible to injury minute surgical procedure the patient had neither if exposed to a secondary insult like mechanical hypotension, nor bradicardia, or any other com- trauma, local anesthetic toxicity, neural is- plication related to the technique. chemia)5. Analgesia was adequate and the level reached Literature reports some cases against regional T6 verified with the pin-prick test and with the anesthesia and the most frequently mentioned is patient’s satisfaction. The duration of anesthesia the one by Levesque et al6. However, in 2006 a was comparable to the one in other pregnant disease revealed by spinal anesthesia was report- women not affected by MS with spinal anesthe- ed7, while Finucane and Terblenche in 2005 re- sia at the same level and with the same amount of ported a prolonged duration of a paravertebral local anesthetic: 60 minutes after neuraxial block supposing that in case of demyelination block, when the patient was transferred to the re- there could be an abnormal uptake of local anes- covery room, the Bromage Score was 4, after 120 thetic8. On the other hand, some Authors prefer minutes it was 3, while after 180 minutes it was epidural anesthesia also in cesarean sections. 1. After three hours in the recovery room, the pa- Nevertheless, after the delivery other conditions tient underwent a complete neurological exami- might confound in case of relapsing disease: the nation that did not show new deficits or exacer- pregnancy, the surgical stress, elevated tempera- bation of the previous neurological symptoms of ture, breast-feeding and only at the end anesthe- the disease. She was then monitored daily 96 sia seems to be involved9. hours after the cesarean section after which she In the last decade, many data suggested that was discharged from the Hospital with no neuro- loco-regional anesthesia is safe in these patients. logical complications occurred. Perlas and Chan claim that MS should not be The follow-up for neurological deficits was considered a contraindication neither for epidural prolonged by one year with clinical examination nor for spinal anesthesia, stressing the concept of after 3, 6, 9, 12 months, all of which showed no a thorough discussion with the patient about the signs of neurological complications. available possibilities10. In the survey by Drake et al2 of the UK obstet- ric anesthetists practice, the Authors find out that the opinion is divided, however, the majority Discussion would use a subarachnoid block for a cesarean although there is still a percentage that would use MS is an acquired demyelinating neurological epidural or general anesthesia. They stress as disease, characterized by remitting neurological well the importance of fully informed consent al- symptoms often followed by stable deficits and so derived from an antenatal assessment.

459 G. Martucci, A. Di Lorenzo, F. Polito, L. Acampa

As examples we also have case reports listed survey of UK experience. Int J Obstet Anesth in PubMed11-13. In the presented case, we per- 2006; 15: 115-123. formed subarachnoid anesthesia because of its 3) AUROY Y, N ARCHI P, M ESSIAH A, LITT L, ROUVIER B, SAMII undisputed advantages in cesarean sections: the K. Serious complications related to regional anes- technique is easier and faster, the block is ex- thesia. Results of a prospective study in France. Anesthesiology 1997; 87: 479-486. tended and profound, the pain control and mus- cular relaxation is optimal during the interven- 4) BADER AM, HUNT CO, DATTA S, NAULTY JS, OSTHEIMER JW. Anesthesia for the obstetric patient with multi- tion, the total dose of local anesthetic adminis- ple sclerosis. J Clin Anesth 1988; 1: 21-24. tered is minimal, the patient is awake and can see the newborn. One of the principal reasons why 5) HEBL JR, HORLOCKER TT, SHROEDER DR. Neuraxial anesthesia and analgesia in patients with preex- we chose this technique were lower volumes and isting central nervous system disorders. Anesth concentrations we can administer in this way. Analg 2006; 103: 223-228. Our results were satisfactory in regard to the 6) LEVESQUE P, M ARSEPOILT, H O P, V ENUTOLO PH, LESOUEF intensity and the level of the block, while the du- JM. Multiple sclerosis revealed by spinal anesthe- ration was comparable to other cases in healthy sia. Ann Fr Anesth Reanim 1988; 7: 68-70. population treated in the same way, and neuro- 7) RABADAN DIAZ JV, LOPEZ MORENO JA, SORIA QUILES A, logic deficits were found neither as transitory DEL PINO MORENO AL. Neurological deficit during ones after the delivery nor during our one-year recovery from cesarean section under spinal follow-up. anesthesia after the appearance of undiagnosed With regard to this rather frequent disease, a multiple sclerosis. Rev Esp Anestesiol Reanim randomized trial and a large cohort of cases 2006; 53: 673-674. would be useful because the practice currently 8) FINUCANE BT, TERBLENCHE OC. Prolonged duration of relies on the opinion of experts’ and personal ex- anesthesia in a patient with multiple sclerosis fol- lowing paravertebral block. Can J Anaesth 2005; perience. 52: 493-497. The choice should be based upon a careful consideration of risks and benefits for each pa- 9) CONFAVREUX C, HUTCHINSON M, HOURS MM, CORTINO- VIS-TOURNIAIRE P, M OREAU T, AND THE PREGNANCY IN tient, taking into account a wide neurologic as- MULTIPLE SCLEROSIS GROUP. Rate of pregnancy-relat- sessment also for subclinical deficits, and of the ed relapse in multiple sclerosis. N Engl J Med patient’s preference. In fact, many Authors sug- 1998; 339: 285-291. gest to actively engage the patient in the deci- 10) PERLAS A, CHAN VW. Neuraxial anesthesia and sion-making process during the antenatal anes- multiple sclerosis. Can J Anaesth 2005; 52: 454- thesiologic assessment. 458. A successful management would evidently be 11) BARBOSA FT, BERNARDO RC, CUNHA RM, PEDROSA S. possible with the cooperation of the anesthetist, Subarachnoid anesthesia for cesarean section in the gynecologist and the neurologist involved in a patient with multiple sclerosis: case report. Rev the peripartum care of this high-risk group of Bras Anestesiol 2007; 57: 301-306. parturients14. 12) INGROSSO M, CIRILLO V, P APASSO A, MEROLLA V, C ECERE F. Femoral and sciatic nerves block (BiBlock) in orthopedic traumatologic lower limbs surgery in patients with multiple sclerosis. Minerva Anestesi- ol 2005; 71: 223-226. References 13) FERREIRA CS, MARQUES MJ, SANTOS MJ, SALGADO H, GONCALVES MB, GOMES CM, OLIVEIRA M. Labour 1) VERCAUTEREN M, HEYTENS L. Anaesthetic considera- analgesia and multiple sclerosis – a case report. tions for patients with a preexisting neurological Reg Anesth Pain Med 2007; 32 Sup: 83. deficit: are neuraxial techniques safe? Acta Anaestesiol Scand 2007; 51: 831-838. 14) KUCZKOWSKI KM. Labor analgesia for the parturient with neurological disease: what does an abstetri- 2) DRAKE E, DRAKE M, BIRD J, RUSSELL R. Obstetric re- cian need to know? Arch Gynecol Obstet 2006; gional blocks for women with multiple sclerosis: a 274: 41-46.

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