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Combined spinal-epidural technique for total hysterectomy in a patient with advanced, progressive multiple sclerosis
540
Regional Anesthesia and Pain Medicine Vol. 27 No. 5 September–October 2002
9. Kyriakides K, Hussain SK, Hobbs GJ. Management of opioidinduced pruritus: A role for 5-HT3 antagonists. Br J Anaesth 1999;82:439-441. 10. Hamel E. The biology of serotonin receptors: Focus on migraine pathophysiology and treatment. Can J Neurol Sci 1999;26:S2-6.
Accepted for publication May 15, 2002. doi:10.1053/rapm.2002.35165
Combined Spinal-Epidural Technique for Total Hysterectomy in a Patient With Advanced, Progressive Multiple Sclerosis To the Editor: Patients with multiple sclerosis (MS) may present with respiratory complications resulting from the involvement of respiratory motor pathways.1,2 The effects of anesthesia and surgery on the course of MS are controversial, and there are concerns regarding the effects of anesthetic management on respiratory function. We cared for a patient with MS and compromised respiratory function who received effective combined epidural-spinal anesthesia (CSE) for total hysterectomy, with no untoward sequelae. In searching the literature, we were unable to find any reports relating to the use of CSE anesthesia in such patients. A 56-year-old woman (70 kg, 163 cm, American Society of Anesthesiologists III) with a 10-year history of MS was admitted for total hysterectomy for endometrial adenocarcinoma 2 weeks after undergoing dilatation and curettage (performed under monitor anesthesia care). Current MS therapy included interferon beta 1a, tizanidine, and complex B vitamins, and her disease was in remission. Neurologic evaluation and symptomatology were consistent with that expected in a patient with a history of MS. The clinical examination was unremarkable except for observed neurologic deficits and the presence of a combined restrictive-obstructive ventilation defect (Table 1). The patient expressed a desire to be awake during surgery, and CSE was chosen (with written informed consent) after discussion, regarding the lack of guidelines concerning this technique in patients with MS and the risk of postoperative ventilatory depression. Before anesthesia induction routine monitoring was established and arterial blood gas sampling was performed repeatedly, supplemental oxygen was provided. CSE was performed with the patient in the left lateral decubitus position. Epidural puncture at the L2-L3 intervertebral space was performed, ropivacaine (3 mL of 0.75%) and fentanyl 25 g in a total volume of 3.5 mL were administered intrathecally through a spinal needle, and an epidural catheter was placed. The dermatomal level of the block was determined by the patient’s verbal responses to cold, touch, and pinprick. Nine minutes after spinal injection, the sensory block was T5, and motor block was a Bromage scale score of 2. At 55 minutes, the patient complained of deep pressure, and supplemental epidural ropivacaine (8 mL of 0.75%) and fentanyl 100 g were administered, but no other medication was given. There were no clinically significant changes in
Table 1. Preoperative Pulmonary Function Test Values Suggestive of a Restrictive-Obstructive Ventilation Defect With Airflow Limitation Parameter
Measured Value
Percent of Predicted Value
FVC FEV1 FEV1/FVC PEFR
1.81 L 1.45 L 80.1% 3.87 L/s
51.0 75.4 -63.0
NOTE. Postoperative values were not clinically different. Abbreviations: FVC, functional vital capacity; FEV1 forced expiratory volume (1st second); PEFR, positive expiratory forced rate.
hemodynamics or dysrhythmias. No vasoactive agents were needed. Respiratory rate was 10 to 12 per minute, and oxygen saturation values were maintained above 98%. The patient was fully alert during the procedure, which was uneventful and lasted 1.75 hours. Postoperatively, the sensory block was T7 and the motor block was a Bromage scale score of 2 and 1 for right and left leg, respectively. There was no provocation of respiratory function: pH 7.45, PaO2 89 mm Hg, PaCO2 42 mm Hg, and arterial oxygen saturation 96%. Pulmonary function tests performed 2 hours after the end of the operation showed no clinically significant changes from preoperative values. Ropivacaine 0.2% and morphine 3.3 g/mL (4 mL/h) were used for postoperative analgesia. Pulmonary function tests performed on the 10th postoperative day were similar to preoperative values. No exacerbation of neurologic signs or symptoms was noted. The patient was discharged 12 days after surgery and was satisfied with the choice of CSE. She denied having neurologic sequelae or disease relapse at 6-month follow-up. This report describes the successful use of CSE in a patient with MS and respiratory impairment. In the absence of consensus or guidelines, the choice of regional or general anesthesia is unclear. Although epidural anesthesia and other regional techniques appear to have no adverse effects, spinal anesthesia has been reported to exacerbate MS3 and may unmask undiagnosed MS4 as has also been reported for local anesthetics.5 We believe that the choice of anesthetic technique must be carefully evaluated on an individual basis. The present case could have been managed with epidural anesthesia alone, which has been reported to be free of an association with ventilatory alterations.6 However, we opted for a combined approach to optimize muscle relaxation and operating conditions. We suggest that the choice of anesthetic technique for patients with MS should be determined after evaluation of the course of the disease, the nature of surgical procedure, and the patient’s desire and that CSE is a viable option in patients without neurologic sequelae and not in relapse. Athina Vadalouca, M.D., Ph.D. Eleni Moka, M.D. Department of Anesthesia Aretaeion University Hospital University of Athens Athens, Greece
Letters to the Editor Constantinos Sykiotis, M.D. Ph.D. Department of Obstetrics and Gynecology Aretaeion University Hospital University of Athens Athens, Greece References 1. Buyse B, Demedts M, Meekers J, Vandegaer L, Rochette F, Kerkhofs L. Respiratory dysfunction in multiple sclerosis: a prospective analysis of 60 patients. Eur Respir J 1997;10: 139-145. 2. Carter JL, Noseworthy JH. Ventilatory dysfunction in multiple sclerosis. Clin Chest Med 1994;15:693-703. 3. Morgan GEJ, Mikhail MS. Anesthesia for patients with neu-
541
rologic and psychiatric disease. In: Mikhail MS, ed. Clinical Anesthesiology. Stamford, CT: Appleton and Lange; 1996: 505-516. 4. Levesque P, Marsepoil T, Ho P, Venutolo F, Lesouef JM. [Multiple sclerosis disclosed by spinal anesthesia][Article in French]. Ann Fr Anesth Reanim 1988;7:68-70. 5. Sakurai M, Mannen T, Kanazawa I, Tanabe H. Lidocaine unmasks silent demyelinative lesions in multiple sclerosis. Neurology 1992;41:2088-2093. 6. Kytta J, Rosenberg PH. Anaesthesia for patients with multiple sclerosis. Ann Chir Gynaecol 1984;73:299-303.
Accepted for publication April 15, 2002. doi:10.1053/rapm.2002.35148
Regional Anesthesia and Pain Medicine Vol. 27 No. 5 September–October 2002
9. Kyriakides K, Hussain SK, Hobbs GJ. Management of opioidinduced pruritus: A role for 5-HT3 antagonists. Br J Anaesth 1999;82:439-441. 10. Hamel E. The biology of serotonin receptors: Focus on migraine pathophysiology and treatment. Can J Neurol Sci 1999;26:S2-6.
Accepted for publication May 15, 2002. doi:10.1053/rapm.2002.35165
Combined Spinal-Epidural Technique for Total Hysterectomy in a Patient With Advanced, Progressive Multiple Sclerosis To the Editor: Patients with multiple sclerosis (MS) may present with respiratory complications resulting from the involvement of respiratory motor pathways.1,2 The effects of anesthesia and surgery on the course of MS are controversial, and there are concerns regarding the effects of anesthetic management on respiratory function. We cared for a patient with MS and compromised respiratory function who received effective combined epidural-spinal anesthesia (CSE) for total hysterectomy, with no untoward sequelae. In searching the literature, we were unable to find any reports relating to the use of CSE anesthesia in such patients. A 56-year-old woman (70 kg, 163 cm, American Society of Anesthesiologists III) with a 10-year history of MS was admitted for total hysterectomy for endometrial adenocarcinoma 2 weeks after undergoing dilatation and curettage (performed under monitor anesthesia care). Current MS therapy included interferon beta 1a, tizanidine, and complex B vitamins, and her disease was in remission. Neurologic evaluation and symptomatology were consistent with that expected in a patient with a history of MS. The clinical examination was unremarkable except for observed neurologic deficits and the presence of a combined restrictive-obstructive ventilation defect (Table 1). The patient expressed a desire to be awake during surgery, and CSE was chosen (with written informed consent) after discussion, regarding the lack of guidelines concerning this technique in patients with MS and the risk of postoperative ventilatory depression. Before anesthesia induction routine monitoring was established and arterial blood gas sampling was performed repeatedly, supplemental oxygen was provided. CSE was performed with the patient in the left lateral decubitus position. Epidural puncture at the L2-L3 intervertebral space was performed, ropivacaine (3 mL of 0.75%) and fentanyl 25 g in a total volume of 3.5 mL were administered intrathecally through a spinal needle, and an epidural catheter was placed. The dermatomal level of the block was determined by the patient’s verbal responses to cold, touch, and pinprick. Nine minutes after spinal injection, the sensory block was T5, and motor block was a Bromage scale score of 2. At 55 minutes, the patient complained of deep pressure, and supplemental epidural ropivacaine (8 mL of 0.75%) and fentanyl 100 g were administered, but no other medication was given. There were no clinically significant changes in
Table 1. Preoperative Pulmonary Function Test Values Suggestive of a Restrictive-Obstructive Ventilation Defect With Airflow Limitation Parameter
Measured Value
Percent of Predicted Value
FVC FEV1 FEV1/FVC PEFR
1.81 L 1.45 L 80.1% 3.87 L/s
51.0 75.4 -63.0
NOTE. Postoperative values were not clinically different. Abbreviations: FVC, functional vital capacity; FEV1 forced expiratory volume (1st second); PEFR, positive expiratory forced rate.
hemodynamics or dysrhythmias. No vasoactive agents were needed. Respiratory rate was 10 to 12 per minute, and oxygen saturation values were maintained above 98%. The patient was fully alert during the procedure, which was uneventful and lasted 1.75 hours. Postoperatively, the sensory block was T7 and the motor block was a Bromage scale score of 2 and 1 for right and left leg, respectively. There was no provocation of respiratory function: pH 7.45, PaO2 89 mm Hg, PaCO2 42 mm Hg, and arterial oxygen saturation 96%. Pulmonary function tests performed 2 hours after the end of the operation showed no clinically significant changes from preoperative values. Ropivacaine 0.2% and morphine 3.3 g/mL (4 mL/h) were used for postoperative analgesia. Pulmonary function tests performed on the 10th postoperative day were similar to preoperative values. No exacerbation of neurologic signs or symptoms was noted. The patient was discharged 12 days after surgery and was satisfied with the choice of CSE. She denied having neurologic sequelae or disease relapse at 6-month follow-up. This report describes the successful use of CSE in a patient with MS and respiratory impairment. In the absence of consensus or guidelines, the choice of regional or general anesthesia is unclear. Although epidural anesthesia and other regional techniques appear to have no adverse effects, spinal anesthesia has been reported to exacerbate MS3 and may unmask undiagnosed MS4 as has also been reported for local anesthetics.5 We believe that the choice of anesthetic technique must be carefully evaluated on an individual basis. The present case could have been managed with epidural anesthesia alone, which has been reported to be free of an association with ventilatory alterations.6 However, we opted for a combined approach to optimize muscle relaxation and operating conditions. We suggest that the choice of anesthetic technique for patients with MS should be determined after evaluation of the course of the disease, the nature of surgical procedure, and the patient’s desire and that CSE is a viable option in patients without neurologic sequelae and not in relapse. Athina Vadalouca, M.D., Ph.D. Eleni Moka, M.D. Department of Anesthesia Aretaeion University Hospital University of Athens Athens, Greece
Letters to the Editor Constantinos Sykiotis, M.D. Ph.D. Department of Obstetrics and Gynecology Aretaeion University Hospital University of Athens Athens, Greece References 1. Buyse B, Demedts M, Meekers J, Vandegaer L, Rochette F, Kerkhofs L. Respiratory dysfunction in multiple sclerosis: a prospective analysis of 60 patients. Eur Respir J 1997;10: 139-145. 2. Carter JL, Noseworthy JH. Ventilatory dysfunction in multiple sclerosis. Clin Chest Med 1994;15:693-703. 3. Morgan GEJ, Mikhail MS. Anesthesia for patients with neu-
541
rologic and psychiatric disease. In: Mikhail MS, ed. Clinical Anesthesiology. Stamford, CT: Appleton and Lange; 1996: 505-516. 4. Levesque P, Marsepoil T, Ho P, Venutolo F, Lesouef JM. [Multiple sclerosis disclosed by spinal anesthesia][Article in French]. Ann Fr Anesth Reanim 1988;7:68-70. 5. Sakurai M, Mannen T, Kanazawa I, Tanabe H. Lidocaine unmasks silent demyelinative lesions in multiple sclerosis. Neurology 1992;41:2088-2093. 6. Kytta J, Rosenberg PH. Anaesthesia for patients with multiple sclerosis. Ann Chir Gynaecol 1984;73:299-303.
Accepted for publication April 15, 2002. doi:10.1053/rapm.2002.35148