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Should laboring parturients with Harrington rods receive lumbar epidural analgesia?
International Journal of Gynecology & Obstetrics 67 Ž1999. 41]43
Brief communication
Should laboring parturients with Harrington rods receive lumbar epidural analgesia? A.M.-H. HoU , W.D. Ngan Kee, D.C. Chung Department of Anaesthesia and Intensi¨ e Care, The Chinese Uni¨ ersity of Hong Kong, Shatin, Hong Kong Received 11 March 1999; received in revised form 10 May 1999; accepted 11 May 1999
Keywords: Epidural analgesia; Labor; Scoliosis corrective surgery
Lumbar epidural analgesia for parturients who have had Harrington rod instrumentation ŽHRI. for spinal fusion is controversial. We highlight the problems with a case report and review of the English literature. A 21-year-old primigravida who had previous HRI for idiopathic scoliosis and a midline T3 to L2 scar requested epidural analgesia for active term labor. An epidural catheter was successfully inserted through the midline at L4]5 on one attempt. A 3-ml lidocaine 1% with 1r200 000 epinephrine test dose followed by 12 ml of bupivacaine 0.25% and fentanyl 100 mg resulted in a block up to T12. The patient required one dose of meperidine 50 mg shortly after epidural catheterization and subsequently Entonox to supplement
U
Corresponding author. Tel.: q852-26322735; fax: q85226372422. E-mail address: [email protected] ŽA.M.-H. Ho.
the hourly doses of epidural bupivacaine. Five hours later, she had a normal spontaneous delivery of a healthy baby. An interview with her the next day and 6 months later revealed no complication. She expressed dissatisfaction with the epidural analgesia. We identified 52 similar cases ŽTable 1. in the literature w1]8x. Inclusive of our own case, catheter placement was successful on the first attempt in 25 Ž47%., satisfactory and uncomplicated analgesia achieved in 29 Ž55%., dural puncture occurred in two Ž4%., and subdural catheterization in another two Ž4%.. Most difficulties appeared in a group of 12 patients w8x whose scars extended down to L5]S1 and attempts at catheterization were made through the scar. The rate of multiple attempts, dural puncture, catheterization failure, and unsatisfactory analgesia Žout of 11 apparently successful epidural catheterizations . in this group was 11r12, 1r12, 1r12, and 6r11, respectively.
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 9 . 0 0 0 8 6 - 7
42
A.M.-H. Ho et al. r International Journal of Gynecology & Obstetrics 67 (1999) 41]43
Table 1 Fifty-two reported cases of lumbar epidural analgesia for parturients with previous Harrington rod instrumentation a Reference
No. of epidural procedures
Insertion attempts
Outcome and complications of block Subdural insertion with extensive sensory block Satisfactory analgesia Ž7., absent analgesia Ž1., dural puncture Ž1. Satisfactory analgesia Ž3. Subdural insertion with extensive sensory block Satisfactory analgesia for labor but inadequate for C-section Satisfactory analgesia Ž9., unsatisfactory analgesia Ž9., low back pain for 2 weeks after multiple epidural attempts Ž1. Unsatisfactory relief from the epidural, needed a rescue spinal Satisfactory analgesia from the four successful attempts
Howard and Anderson w1x
1
Multiple attempts
Crosby and Halpern w2x
9
Feldstein and Ramanathan w3x Lee et al. w4x
3 1
Single attempt Ž5., multiple attempts Ž4. Single attempt Ž3. Multiple attempts
Pascoe et al. w5x
1
Single attempt
Daley et al. w6x
19
Silva and Popat w7x Hubbert w8x
Hubbert w8x
1 5 Žinserted caudal to the lowest point of the spinal fusion scar. 12 Žinserted cephalad to the lowest point of the spinal fusion scar.
Single attempt Ž10., multiple attempts Ž8., failed attempt Ž1. Single attempt Single attempt Ž4. failed attempts Ž1.
Single attempt Ž1., multiple attempts Ž11.
Satisfactory analgesia Ž5., unsatisfactory analgesia Ž6., dural puncture with satisfactory analgesia Ž1.
a All insertion attempts were caudal to the lowest point of the spinal fusion scar except in a sub-group of 12 patients Žlast row. in Hubbert’s series w8x.
In the other 40 cases w1]8x and ours, insertions were made caudal to the scar. Catheterization on the first attempt occurred in 25 Ž59%., apparent successful catheterization after multiple attempts in 14 Ž34%, one was complicated by dural puncture and two turned out to be subdural catheterizations., and unsuccessful multiple attempts in two Ž5%.. Of these 41 cases, 24 Ž56%. had satisfactory analgesia. Insertion through the scar was associated with a greater chance of requiring multiple attempts when compared to insertion caudal to the scar Ž11r12 vs. 16r41, x 2 , Ps 0.001., but both approaches had similar rates of dural puncture and unsatisfactory analgesia. There was no case of spine infection, headache, or long-term back pain. Insertion difficulties were likely due to the presence of instrumentation and scarring changes. Of note is the high rate of dural puncture Ž2r53 or
4%. and of subdural catheterization Ž2r53 or 4%.. In summary, lumbar epidural analgesia may be administered to patients with HRI. However, there are greater chances of difficult insertion Žespecially through the scar., dural puncture, subdural catheterization, unsatisfactory analgesia, and failure. So far no long-term sequelae has been reported. Early consultation with an anesthesiologist is recommended. References w1x Howard R, Anderson W. Subdural catheterization and opiate administration in a patient with Harrington rods. Can J Anaesth 1990;37:712. w2x Crosby ET, Halpern SH. Obstetric epidural anaesthesia in patients with Harrington instrumentation. Can J Anaesth 1989;36:693]696. w3x Feldstein G, Ramanathan S. Obstetrical lumbar epidural
A.M.-H. Ho et al. r International Journal of Gynecology & Obstetrics 67 (1999) 41]43 anesthesia in patients with previous posterior spinal fusion for kyphoscoliosis. Anesth Analg 1985;64:83]85. w4x Lee Y-SJ, Bundschu RH, Moffat EC. Unintentional subdural block during labor epidural in a parturient with prior Harrington rod insertion for scoliosis. Reg Anesth 1995;20:159]162. w5x Pascoe HF, Jennings GS, Marx GF. Successful spinal anesthesia after inadequate epidural block in a parturient with prior surgical correction of scoliosis. Reg Anesth 1993;18:191]192.
43
w6x Daley MD, Rolbin SH, Hew EM, Morningstar BA, Stewart JA. Epidural anesthesia for obstetrics after spinal surgery. Reg Anesth 1990;15:280]284. w7x Silva TSS, Popat MT. Combined spinal-epidural anesthesia in parturient with Harrington Rods. Reg Anesth 1994;19:360. w8x Hubbert CH. Epidural anesthesia in patients with spinal fusion. Anesth Analg 1985;64:843.
Brief communication
Should laboring parturients with Harrington rods receive lumbar epidural analgesia? A.M.-H. HoU , W.D. Ngan Kee, D.C. Chung Department of Anaesthesia and Intensi¨ e Care, The Chinese Uni¨ ersity of Hong Kong, Shatin, Hong Kong Received 11 March 1999; received in revised form 10 May 1999; accepted 11 May 1999
Keywords: Epidural analgesia; Labor; Scoliosis corrective surgery
Lumbar epidural analgesia for parturients who have had Harrington rod instrumentation ŽHRI. for spinal fusion is controversial. We highlight the problems with a case report and review of the English literature. A 21-year-old primigravida who had previous HRI for idiopathic scoliosis and a midline T3 to L2 scar requested epidural analgesia for active term labor. An epidural catheter was successfully inserted through the midline at L4]5 on one attempt. A 3-ml lidocaine 1% with 1r200 000 epinephrine test dose followed by 12 ml of bupivacaine 0.25% and fentanyl 100 mg resulted in a block up to T12. The patient required one dose of meperidine 50 mg shortly after epidural catheterization and subsequently Entonox to supplement
U
Corresponding author. Tel.: q852-26322735; fax: q85226372422. E-mail address: [email protected] ŽA.M.-H. Ho.
the hourly doses of epidural bupivacaine. Five hours later, she had a normal spontaneous delivery of a healthy baby. An interview with her the next day and 6 months later revealed no complication. She expressed dissatisfaction with the epidural analgesia. We identified 52 similar cases ŽTable 1. in the literature w1]8x. Inclusive of our own case, catheter placement was successful on the first attempt in 25 Ž47%., satisfactory and uncomplicated analgesia achieved in 29 Ž55%., dural puncture occurred in two Ž4%., and subdural catheterization in another two Ž4%.. Most difficulties appeared in a group of 12 patients w8x whose scars extended down to L5]S1 and attempts at catheterization were made through the scar. The rate of multiple attempts, dural puncture, catheterization failure, and unsatisfactory analgesia Žout of 11 apparently successful epidural catheterizations . in this group was 11r12, 1r12, 1r12, and 6r11, respectively.
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 9 . 0 0 0 8 6 - 7
42
A.M.-H. Ho et al. r International Journal of Gynecology & Obstetrics 67 (1999) 41]43
Table 1 Fifty-two reported cases of lumbar epidural analgesia for parturients with previous Harrington rod instrumentation a Reference
No. of epidural procedures
Insertion attempts
Outcome and complications of block Subdural insertion with extensive sensory block Satisfactory analgesia Ž7., absent analgesia Ž1., dural puncture Ž1. Satisfactory analgesia Ž3. Subdural insertion with extensive sensory block Satisfactory analgesia for labor but inadequate for C-section Satisfactory analgesia Ž9., unsatisfactory analgesia Ž9., low back pain for 2 weeks after multiple epidural attempts Ž1. Unsatisfactory relief from the epidural, needed a rescue spinal Satisfactory analgesia from the four successful attempts
Howard and Anderson w1x
1
Multiple attempts
Crosby and Halpern w2x
9
Feldstein and Ramanathan w3x Lee et al. w4x
3 1
Single attempt Ž5., multiple attempts Ž4. Single attempt Ž3. Multiple attempts
Pascoe et al. w5x
1
Single attempt
Daley et al. w6x
19
Silva and Popat w7x Hubbert w8x
Hubbert w8x
1 5 Žinserted caudal to the lowest point of the spinal fusion scar. 12 Žinserted cephalad to the lowest point of the spinal fusion scar.
Single attempt Ž10., multiple attempts Ž8., failed attempt Ž1. Single attempt Single attempt Ž4. failed attempts Ž1.
Single attempt Ž1., multiple attempts Ž11.
Satisfactory analgesia Ž5., unsatisfactory analgesia Ž6., dural puncture with satisfactory analgesia Ž1.
a All insertion attempts were caudal to the lowest point of the spinal fusion scar except in a sub-group of 12 patients Žlast row. in Hubbert’s series w8x.
In the other 40 cases w1]8x and ours, insertions were made caudal to the scar. Catheterization on the first attempt occurred in 25 Ž59%., apparent successful catheterization after multiple attempts in 14 Ž34%, one was complicated by dural puncture and two turned out to be subdural catheterizations., and unsuccessful multiple attempts in two Ž5%.. Of these 41 cases, 24 Ž56%. had satisfactory analgesia. Insertion through the scar was associated with a greater chance of requiring multiple attempts when compared to insertion caudal to the scar Ž11r12 vs. 16r41, x 2 , Ps 0.001., but both approaches had similar rates of dural puncture and unsatisfactory analgesia. There was no case of spine infection, headache, or long-term back pain. Insertion difficulties were likely due to the presence of instrumentation and scarring changes. Of note is the high rate of dural puncture Ž2r53 or
4%. and of subdural catheterization Ž2r53 or 4%.. In summary, lumbar epidural analgesia may be administered to patients with HRI. However, there are greater chances of difficult insertion Žespecially through the scar., dural puncture, subdural catheterization, unsatisfactory analgesia, and failure. So far no long-term sequelae has been reported. Early consultation with an anesthesiologist is recommended. References w1x Howard R, Anderson W. Subdural catheterization and opiate administration in a patient with Harrington rods. Can J Anaesth 1990;37:712. w2x Crosby ET, Halpern SH. Obstetric epidural anaesthesia in patients with Harrington instrumentation. Can J Anaesth 1989;36:693]696. w3x Feldstein G, Ramanathan S. Obstetrical lumbar epidural
A.M.-H. Ho et al. r International Journal of Gynecology & Obstetrics 67 (1999) 41]43 anesthesia in patients with previous posterior spinal fusion for kyphoscoliosis. Anesth Analg 1985;64:83]85. w4x Lee Y-SJ, Bundschu RH, Moffat EC. Unintentional subdural block during labor epidural in a parturient with prior Harrington rod insertion for scoliosis. Reg Anesth 1995;20:159]162. w5x Pascoe HF, Jennings GS, Marx GF. Successful spinal anesthesia after inadequate epidural block in a parturient with prior surgical correction of scoliosis. Reg Anesth 1993;18:191]192.
43
w6x Daley MD, Rolbin SH, Hew EM, Morningstar BA, Stewart JA. Epidural anesthesia for obstetrics after spinal surgery. Reg Anesth 1990;15:280]284. w7x Silva TSS, Popat MT. Combined spinal-epidural anesthesia in parturient with Harrington Rods. Reg Anesth 1994;19:360. w8x Hubbert CH. Epidural anesthesia in patients with spinal fusion. Anesth Analg 1985;64:843.