Combined spinal-epidural anesthesia in a patient with spinal muscular atrophy type II undergoing a cesarean section: A case report

Slavica Krušić; Branka  Nikolić; Rastko  Maglić

doi:10.2298/VSP180224074K

Slavica Krušić Obstetrics and Gynecology Clinic "Narodni front”, Belgrade, Serbia
Branka Nikolić Obstetrics and Gynecology Clinic “Narodni front” Belgrade, Serbia; University of Belgrade, Faculty of Medicine
Rastko Maglić Obstetrics and Gynecology Clinic “Narodni front” Belgrade, Serbia; University of Belgrade, Faculty of Medicine

DOI: https://doi.org/10.2298/VSP180224074K

Keywords: labor;, cesarean section;, myotonic disorders;, anesthesia, epidural;, anesthesia, spinal

Abstract

Introduction. Anesthetic management of a patient with spinal muscular atrophy type II, who underwent elective cesarean section with neuraxial anesthesia is presented in this case report. Case report. A 33-year old woman with first pregnancy and no previous birth, at 39 weeks gestational age was scheduled for a cesarean section due to placenta previa. She had a history of spinal muscular atrophy type II, that confined her to a wheelchair, and a surgical history that included corrective surgery for kyphoscoliosis. The patient had predictors for a difficult intubation (limited mouth opening and reduced neck extension) so the decision was made to attempt the needle-through-needle combined spinal-epidural technique for surgical anesthesia. Harrington rods and scar tissue complicated placement of the combined spinal-epidural anesthesia, however successful placement was achieved. Conclusion. Spinal muscular atrophy in pregnancy is rare and represents big challenge for an anesthesiologist due to respiratory dysfunction, anticipated difficult intubation, severe kyphoscoliosis and limitations of the use neuromuscular blocking agents. The potential risks need to be considered when administering anesthesia in patients with spinal muscular atrophy undergoing a cesarean section.

References

D’Amico A, Mercuri E, Tiziano FD, Bertini E. Spinal muscular atrophy. Orphanet J Rare Dis 2011; 6(1): 71.

Flunt D, Andreadis N, Menadue C, Welsh AW. Clinical commen¬tary: obstetric and respiratory management of pregnancy with severe spinal muscular atrophy. Obstet Gynecol Int 2009; 2009: 942301.

Özhan MÖ, Süzer MA, Eşkin MB, Çaparlar C, Atik B, Fener N. Combined spinal epidural anesthesia for cesarean section in a parturient with spinal muscular atrophy type III. Anestezi Dergisi 2012; 20(2): 119–122. (Turkish)

McLoughlin L, Bhagvat P. Anaesthesia for caesarean section in spinal muscular atrophy type III. Int J Obstet Anesth 2004; 13(3): 192–5.

Habib AS, Muir HA. Tracheal intubation without muscle relaxants for caesarean section in patients with spinal muscular atrophy. Int J Obstet Anesth 2005; 14(4): 366–7.

Bollag L, Kent CD, Richebe P, Landau R. Anesthetic management of spinal muscular atrophy type II in a parturient. Local Reg Anesth 2011; 4: 15–20.

Harris SJ, Moaz K. Caesarean section conducted under subarachnoid block in two sisters with spinal muscular atrophy. Int J Obstet Anesth 2002; 11(2): 125–7.

Buettner AU. Anaesthesia for caesarean section in a patient with spi¬nal muscular atrophy. Anaesth Intensive Care 2003; 31(1): 92–4.

Rudnik-Schöneborn S, Zerres K, Ignatius J, Rietschel M. Pregnancy and spinal muscular atrophy. J Neurol 1992; 239(1): 26–30.

Maruotti GM, Anfora R, Scanni E, Rispoli M, Mazzarelli LL, Napolitano R, et al. Anesthetic management of a parturient with spinal muscular atrophy type II. J Clin Anesth 2012; 24(7): 573–7.

Gaca M, Kokot N, Koziolek A, Kuczkowski KM. Combined spinal epidural anesthesia for cesarean section in a parturient with spinal muscle atrophy type III (Kugelberg-Walendar disease). J Matern Fetal Neonatal Med 2011; 24(1): 195.

Howarth L, Glanville T. Management of a pregnancy compli-cated by type III spinal muscular atrophy. BMJ Case Rep 2011; 2011. pii: bcr1020103402.

Burnett T, Halim M. Local anesthetic infiltration for cesarean section in a patient with spinal muscular atrophy type II. In: SOAP 42nd Annual Meeting; 2010 May 12–16; San Antonio (TX). Abstract 132.

Coffman JC, Fiorini K, Ristev G, Beeston W, Small RH. Trans¬ver-sus abdominis plane and ilioinguinal/iliohypogastric blocks for cesarean delivery in a patient with type II spinal muscular atrophy. Int J Obstet Anest 2016; 25: 79‒81.

Liu X, Wang D, Ma D. Using General Anesthesia plus Muscle Relaxant in a Patient with Spinal Muscular Atrophy Type IV: A Case Report. Case Rep Anesthesiol. 2011; 2011: 743587.

Pugh CP, Healey SK, Crane JM, Young D. Successful pregnancy and spinal muscular atrophy. Obstet Gynecol 2000; 95 (6 Pt 2): 1034.

Neumann MM, Davio MB, Macknet MR, Applegate RL 2nd. Dexmedetomidine for awake fiberoptic intubation in a parturient with spinal muscular atrophy type III for cesarean delivery. Int J Obstet Anesth 2009; 18(4): 403–7.

Kitson R, Williams V, Howell C. Caesarean section in a parturient with type III spinal muscular atrophy and pre-eclampsia. Anaesthesia 2004; 59(1): 94–5.

Stewart PA, Phillips S, De Boerc HD. Sugammadex reversal of rocuronium-induced neuromuscular blockade in two types of neuromuscular disorders: Myotonic dystrophy and spinal muscular atrophy. Rev Esp Anestesiol Reanim 2013; 60(4): 226–9.

Fang Q, Gao G, An J, Liu C, Qian X, Wen H et al. Total intravenous anesthesia for cesarean section in a pregnant woman with spinal muscular atrophy. Chin Med J 2014; 127(18): 3350–1.