Problemsspecial considerations

The initial problem is one of diagnosis. Different lesions may present in different ways that may overlap with each other and with other conditions (Table 51.1). Although cord lesions generally present with upper motor neurone signs and sensory impairment below the level of injury, and peripheral nerve injuries present with lower motor neurone signs, it may be surprisingly difficult to distinguish them clinically (see Chapter 50, Peripheral nerve lesions following regional

51 Spinal cord lesions following regional anaesthesia 131

Table 51.1. Causes of postpartum spinal cord lesions

Mechanism

Condition

Comment

Compression

Epidural haematoma

May be associated with back pain

Epidural abscess

Associated with back pain plus

evidence of local and/or systemic

infection; typically presents several

days postpartum

Prolapsed disc

Associated with back pain; may

present de novo intra- or

postpartum

Tumour

May be associated with back pain

Ischaemia*

Severe hypotension

Not associated with back pain

Anomalous arterial blood

Includes arteriovenous malforma-

supply plus prolonged

tions or a predominantly pelvic

labour or hypotension

blood supply to the conus

medularis and cauda equina

Normal vascular supply and

Has been reported in spinal stenosis

normotension

following rapid injection of a large

epidural bolus

Neurotoxicity

Injection of wrong solution

May be associated with back pain

Trauma

Back injury

Associated with back pain

Direct damage during

May be associated with back pain

regional anaesthesia

although paraesthesia is more

common

*N.B. compression results in local ischaemia.

*N.B. compression results in local ischaemia.

anaesthesia, p. 128). Sinister signs such as pyrexia, severe back pain, bilateral distribution, or loss of bladder or bowel function are suggestive of a compressive lesion such as epidural or spinal haematoma/abscess. These conditions are very rare (less than 1 in 100 000) but may cause major, irreversible damage unless relieved within hours of presentation. Any suspicion should prompt immediate referral for a neurosurgical opinion. In the case of early lesions, some effects of spinal or epidural blockade may persist for several hours, occasionally over 12 hours (up to 48 hours has been reported after epidural blockade, with no apparent cause), obscuring the underlying pathology. Since regression of a block often occurs under observation by non-anaesthetic staff, there may be delay in appropriate medical input being requested. In the case of acute potentially reversible spinal cord damage, e.g. cord compression caused by haematoma, delay of more than 6-8 hours is associated with an increasing chance of permanent impairment.

Similarly, problems that present later, such as epidural abscess, may be missed if associated back pain is dismissed as trivial.

132 Section 2 - Pregnancy Management options

Anaesthetic-related problems may be reduced by attention to details such as:

• Assessing the coagulation status and pre-existing neurological status before performing regional techniques

• Aseptic technique

• Determining appropriate anatomical landmarks during the procedure and awareness of the risk of and from inserting the needle too high

• Removal of the needle if severe parasthesia or pain is experienced during a regional block

• Prevention and management of hypotension after anaesthesia.

Any unexpectedly dense or prolonged block should always be observed carefully, especially if other risk factors (e.g. heparin therapy) are present. A careful history and examination, and knowledge of the relevant anatomy, are vital to distinguish the various lesions from less severe conditions, and neurological referral is always advisable if there is any suspicion.

Individual conditions are managed as for non-pregnant patients, e.g. surgical decompression for cord compression, plus antibiotics for abscess.

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