Chiari I malformation

[seinfeld]

---

Members don't see this ad.

25 y/o G1P0 at 39 weeks, BMI <25, comes in labor requesting epidural. Pt has hx of Chiari 1 malformation first diagnosed in 6 years ago after pt reported hx of HA's. MRI showed at that time 9mm herniation of cerebellar tonsil. Since that time the patients headaches have become non existent except for occasional tension/stress HA and MRI studies have shown improvement in in herniation 5mm. No obstruction of CSF flow or signs of increased ICP on most recent MRI.

Would you do a central neuroaxial technique? For labor? For C-section?

If No, at what BMI, if any, would you consider it more strongly?

I have heard many different opinions so i figured a few more wouldn't hurt.

 

[Planktonmd]

25 y/o G1P0 at 39 weeks, BMI <25, comes in labor requesting epidural. Pt has hx of Chiari 1 malformation first diagnosed in 6 years ago after pt reported hx of HA's. MRI showed at that time 9mm herniation of cerebellar tonsil. Since that time the patients headaches have become non existent except for occasional tension/stress HA and MRI studies have shown improvement in in herniation 5mm. No obstruction of CSF flow or signs of increased ICP on most recent MRI.

Would you do a central neuroaxial technique? For labor? For C-section?

If No, at what BMI, if any, would you consider it more strongly?

I have heard many different opinions so i figured a few more wouldn't hurt.

The short answer is: sorry, no Neuraxial anesthesia.
There is 2 issues:
1- Possible increased ICP and exacerbation of herniation.
2- Many of these patients have syrinx formation in the spinal cord so if she currently has one you don't want to put a needle next to it, if she develops one later you might be blamed for causing it by penetrating the cord although it is caused by the disease itself.
So, no neuraxial regardless of how big she is.

 

[militarymd]

25 y/o G1P0 at 39 weeks, BMI <25, comes in labor requesting epidural. Pt has hx of Chiari 1 malformation first diagnosed in 6 years ago after pt reported hx of HA's. MRI showed at that time 9mm herniation of cerebellar tonsil. Since that time the patients headaches have become non existent except for occasional tension/stress HA and MRI studies have shown improvement in in herniation 5mm. No obstruction of CSF flow or signs of increased ICP on most recent MRI.

Would you do a central neuroaxial technique? For labor? For C-section?

If No, at what BMI, if any, would you consider it more strongly?

I have heard many different opinions so i figured a few more wouldn't hurt.

You said it right there.......No contraindications to anything....but if one is a puss and one is afraid of lawyers, then IV PCA for pain management...and GA for c-section....which as we all know (sarcasm intended) is 100 times for likely to cause death in the parturient.

 

[urge]

The short answer is: sorry, no Neuraxial anesthesia.
There is 2 issues:
1- Possible increased ICP and exacerbation of herniation.
2- Many of these patients have syrinx formation in the spinal cord so if she currently has one you don't want to put a needle next to it, if she develops one later you might be blamed for causing it by penetrating the cord although it is caused by the disease itself.
So, no neuraxial regardless of how big she is.

WTF?!! 😱

 

[Planktonmd]

WTF?!! 😱

Was that an attempt at saying something with a remote trace of intelligence?

 

[Planktonmd]

You said it right there.......No contraindications to anything....but if one is a puss and one is afraid of lawyers, then IV PCA for pain management...and GA for c-section....which as we all know (sarcasm intended) is 100 times for likely to cause death in the parturient.

So you are advocating placing a needle in someone's back without knowing if they have Syringomyelia or not, and you are saying that you can tell that the ICP is normal based on an MRI that we don't even know when it was done!
Is that because you know things we don't know or because you are trying to remind us of how brave and fearless you are?

 

[militarymd]

Chiari I.....by definition ...is a simple anatomic curiosity..essentially benign...and with no clinical significance.....syrinx in type I???? are you sure about that?

 

[Idiopathic]

I think you guys are wrong about this one. Chiari I is not benign. Im not sure about this particular case, but syringomyelia and symptoms are certainly possibilities.

 

[Noyac]

If it is at 2am and she is calling for an epidural I so sorry.

But really, I would probably perform a neuraxial anesthetic with a very detailed informed consent and physical exam.

here are some references:
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Link&db=PubMed&dbFrom=PubMed&from_uid=14607053

 

[militarymd]

So you are advocating placing a needle in someone's back without knowing if they have Syringomyelia or not, and you are saying that you can tell that the ICP is normal based on an MRI that we don't even know when it was done!
Is that because you know things we don't know or because you are trying to remind us of how brave and fearless you are?

Just looked it up ....for some reason I though syringomyelia is associated with higher grade AC malformations, but I guess i was wrong...

however, I stand by my statement regarding regional.

If there's no obstruction to CSF flow..no problem..

 

[urge]

Would any of the residents care to comment on why an epidural might be a good idea in a chiari laboring pt?

 

[seinfeld]

Well these discussions are in line with previous i have had. I found one reference from Mayo which seemed to suggest its safe in patients without increased ICP. There was interesting subset who were dx after L&D. In this case the patient was sent for MRI merely for HA's with no neurologic s/s, she was the neurotic type. I wonder how many patients i have placed epidurals and spinals who never had an MRI but who did have this abnormality?

Robert C. Chantigian, MD,* Monica A. Koehn, MD,† Kirk D. Ramin, MD,‡ Mark A. Warner, MD, Chiari I Malformation in Parturients . J Clin. Anesth., vol. 14, May 2002,

For more followup, the pt never actually go the chance to ask for an epidural. the pts OB sent her to a neurologist in her 38th week who promptly told her that epidural and spinal were out. I found it a little annoying that the OB refused to allow her to talk with an anesthesiologist about here options around the same time given the neurologist has little knowledge of the risks and benefits of different anesthetic techniques surrounding OB.

Thanks

 

[seinfeld]

Would any of the residents care to comment on why an epidural might be a good idea in a chiari laboring pt?

Some may say that the valsalva like manuever of pushing during labor may actually lead to an increase in cerebral venous congestion and thus an increase in ICP

 

[DrDre']

I would put an OPA in and not intubate.

You said it right there.......No contraindications to anything....but if one is a puss and one is afraid of lawyers, then IV PCA for pain management...and GA for c-section....which as we all know (sarcasm intended) is 100 times for likely to cause death in the parturient.

 

[urge]

Some may say that the valsalva like manuever of pushing during labor may actually lead to an increase in cerebral venous congestion and thus an increase in ICP

Right!

Now, regarding the syrinx formation. Where does it occur? At what level do we place labor epidurals? Can you get close to a syrinx with the needle while doing it?

 

[Planktonmd]

Some may say that the valsalva like manuever of pushing during labor may actually lead to an increase in cerebral venous congestion and thus an increase in ICP

I don't get it, are you saying that because labor might increase ICP it's a good idea to place an epidural?
And what happens if you wet tap the patient with a # 17 Tuhoy?

 

[militarymd]

with no obstruction to CSF flow....nothing.

posterior fossa malformation does not equate obstruction of the foramen of morgagni....or is it Luschka...???

 

[Planktonmd]

with no obstruction to CSF flow....nothing.

posterior fossa malformation does not equate obstruction of the foramen of morgagni....or is it Luschka...???

No this is not the issue. They are saying in someone with Chiari malformation and increased ICP, that because labor could cause epidural venous congestion and subsequently increase ICP further, it is a good idea to place an epidural to decrease that venous congestion!
There is 2 issues with that theory:
1- The epidural will require injecting a volume of local anesthetic in the epidural space and causing more increase of CSF pressure that will eliminate any possible beneficial effect on the venous congestion. This will be even worse if there is Syrinx occupying space in the spinal cord.
2- If you wet tap the patient you might cause acute exacerbation of the herniation.
So, I don't see the benefit of an epidural to chiari patient in labor.

 

[militarymd]

No this is not the issue. They are saying in someone with Chiari malformation and increased ICP, that because labor could cause epidural venous congestion and subsequently increase ICP further, it is a good idea to place an epidural to decrease that venous congestion!
There is 2 issues with that theory:
1- The epidural will require injecting a volume of local anesthetic in the epidural space and causing more increase of CSF pressure that will eliminate any possible beneficial effect on the venous congestion. This will be even worse if there is Syrinx occupying space in the spinal cord.
2- If you wet tap the patient you might cause acute exacerbation of the herniation.
So, I don't see the benefit of an epidural to chiari patient in labor.

why?? if there is no obstruction of csf flow?

As for Syrinx....after some reading are higher up (cervical/thoracic regions)on the spine than where lumbar epidurals are placed....and how does a space occupying lesion inside the cord affect place ment of a extra spinal cord anesthetic.

 

[Planktonmd]

why?? if there is no obstruction of csf flow?

As for Syrinx....after some reading are higher up (cervical/thoracic regions)on the spine than where lumbar epidurals are placed....and how does a space occupying lesion inside the cord affect place ment of a extra spinal cord anesthetic.

We don't know if there is no obstruction!
Most of the Syrinx are cervical or thoracic but could be anywhere in the cord, and the existance of a space occupying lesion in the cord would cause narrowing of the epidural space, so injecting volume would more likely cause increased CSF pressure.
In addition to that, injecting volume in the epidural space in the presence of a syrinx could cause cord compression regardless of where you place your epidural relative to the syrinx.
It's not as simple as many people would imagine.

 

[militarymd]

We don't know if there is no obstruction!
Most of the Syrinx are cervical or thoracic but could be anywhere in the cord, and the existance of a space occupying lesion in the cord would cause narrowing of the epidural space, so injecting volume would more likely cause increased CSF pressure.
In addition to that, injecting volume in the epidural space in the presence of a syrinx could cause cord compression regardless of where you place your epidural relative to the syrinx.
It's not as simple as many people would imagine.

If there is obstruction of CSF, there will be hydrocephalus....compression of posterior fossa contents (cerebellum & friends) by bony structures can cause pain, but that does not equate CSF obstruction....if you obstruct CSF flow (tumor, subarachnoid hemorrhage, etc.) you will develop hydrocephalus.

"narrowing of the epidural space"? ......I thought the epidural space is a potential space...

Since when do we inject local anesthetic under pressure?? Local injected into the potential epidural space is gone in minutes....blood hangs around a little, that's why it works for intracranial hypotension syndromes (spinal headache)......local is asbsorbed VERY quickly.....local anesthetic effect lasts....

You are repeating a lot of dogma that should go into the other thread...Jet's myth.

 

[urge]

Most of the Syrinx are cervical or thoracic but could be anywhere in the cord, and the existance of a space occupying lesion in the cord would cause narrowing of the epidural space, so injecting volume would more likely cause increased CSF pressure.

So now the argument changes. Used to be that you don't want to get close to the syrinx with the epidural needle, or be blamed for causing one. I don't know how you can picture a syrinx in the cauda equina where there is no cord. Must be good imagination.

Now the argument is that the ICP will not allow it. This is where you have to do a detailed H+P. Is the pt having signs/symptoms of increased ICP. If they have it's a no brainer. If they don't then you have to ask your self if 10ml of bupi .2% will tip them over. Will it go from an icp of 10-15 to and icp of 20-25? IMHO, the chances of this happening are very low in a asymptomatic pt, especially if you inject 2 ml at a time and ask if it's being tolerated.

More so, shouldn't a pt with advanced disease and syrinx formation have a VP shunt or a decompression?

 

[urge]

You are repeating a lot of dogma that should go into the other thread...Jet's myth.

Cool! Myths perpetuated by Private Practice...

1 You can intubate everyone with a miller 2
2 you can get syringomyelia in areas where there is no spinal cord.

more to come....

 

[lobelsteve]

We don't know if there is no obstruction!
Most of the Syrinx are cervical or thoracic but could be anywhere in the cord, and the existance of a space occupying lesion in the cord would cause narrowing of the epidural space, so injecting volume would more likely cause increased CSF pressure.
In addition to that, injecting volume in the epidural space in the presence of a syrinx could cause cord compression regardless of where you place your epidural relative to the syrinx.
It's not as simple as many people would imagine.

1. Obstruction: Signs and symptoms-

Blurred or double vision
Cognitive difficulties
Downward gaze or "sun-setting eyes"
Headache
Imbalance and dizziness
Incontinence
Irregular gait
Lethargy
Nausea
Poor coordination
Visual disturbances
Vomiting
Weakness

We could put in a Camino bolt kit or get an opening pressure on LP, but in vivo human studies (clinical situations) this would be unwise.

2. Syrinx- generally accepted that 1-2mm are rarely symptomatic. A syrinx would have to reach such an enormous size that the cord would be obliterated before any epidural encroachment could occur. Think of the dura filled with CSF and no cord, it still would not create an outpouching of the dura.

3. Injectng an epidural volume sufficient to change pressure in the CSF would likely need to be at least 50cc unless there were epidural adhesions limiting the flow of fluid through the epidural space or if hypertonic saline was used.

Claims data:

Half of the 63 nerve injury claims involved spinal cord injury, including 14 epidural steroid injections, six of which resulted in paraplegia and one quadriplegia. Other procedures associated with nerve injury involving the spinal cord included blocks (5), ablative procedures (3), cervical facet (1), implantation or removal of devices (2) and device maintenance (4). There were 18 claims for paraplegia or quadriplegia, and they included epidural abscess (4), chemical injury from injection into the spinal cord (8) and epidural hematoma (4). Other nerve injury claims included the lumbosacral nerve root (21), the sciatic nerve (2) and the brachial plexus (2).

There were 59 claims for pneumothorax, 40 of which were associated with blocks and 18 from injections, predominantly trigger-point injections. More than half (34) of the patients were diagnosed with pneumothorax after they had been discharged, and of these, 15 patients were diagnosed and treated in an emergency room.

Infection accounted for 13 percent of all claims from invasive procedures. Most were associated with epidural steroid injections and some with implantation, removal or maintenance of implanted devices. Meningitis (12) was the most common presentation followed by epidural abscess (7) and osteomyelitis (3). Surgical intervention was required in six of the seven epidural abscesses with one patient sustaining permanent neurological deficits.

Claims for death or brain damage were associated with epidural steroid injections (9) and device maintenance (9). Of the 114 claims related to epidural steroid injections, 61 of the injections used local anesthetics and or opioids. All nine epidural steroid injections resulting in death or brain damage contained local anesthetics with or without opioids [Figure 2]. Events include unintended intrathecal injection (5), allergic reaction (1), cardiovascular collapse and respiratory depression from inadvertent intrathecal injection at the thoracic level (1), and delayed respiratory depression from epidural morphine administered with the steroid (3).

4. Epidurals and syrinx occur this way: http://medpics.findlaw.com/enlargeexhibit.php?ID=13490

I'm such a PITA. mil already capped this argument.

 

[gasnewby]

i like the "medical school for lawyers, only $395!" on that link

 

[Planktonmd]

So now the argument changes. Used to be that you don't want to get close to the syrinx with the epidural needle, or be blamed for causing one. I don't know how you can picture a syrinx in the cauda equina where there is no cord. Must be good imagination.

Now the argument is that the ICP will not allow it. This is where you have to do a detailed H+P. Is the pt having signs/symptoms of increased ICP. If they have it's a no brainer. If they don't then you have to ask your self if 10ml of bupi .2% will tip them over. Will it go from an icp of 10-15 to and icp of 20-25? IMHO, the chances of this happening are very low in a asymptomatic pt, especially if you inject 2 ml at a time and ask if it's being tolerated.

More so, shouldn't a pt with advanced disease and syrinx formation have a VP shunt or a decompression?

And when you do a labor epidural you usually do a detailed neurological exam don't you?
Do you even know how to do real neurological exam junior?
You are assuming that all the patients come to you already fully diagnosed and worked up don't you?
My arguments never changed and I repeat them to you:
If you don't have ALL THE DATA don't stick a needle in a patient with chiari malformation because you don't know what you are doing.

 

[Planktonmd]

If there is obstruction of CSF, there will be hydrocephalus....compression of posterior fossa contents (cerebellum & friends) by bony structures can cause pain, but that does not equate CSF obstruction....if you obstruct CSF flow (tumor, subarachnoid hemorrhage, etc.) you will develop hydrocephalus.

"narrowing of the epidural space"? ......I thought the epidural space is a potential space...

Since when do we inject local anesthetic under pressure?? Local injected into the potential epidural space is gone in minutes....blood hangs around a little, that's why it works for intracranial hypotension syndromes (spinal headache)......local is asbsorbed VERY quickly.....local anesthetic effect lasts....

You are repeating a lot of dogma that should go into the other thread...Jet's myth.

You are trying to argue for the sake of argument here.
The bottom line:
There is no solid data on the proper management for these patients.
There is some case reports on successful epidurals and spinals but not enough to establish a safe standard of practice.
I truly think that these cases have to be taken seriously and unless you are 100 % sure of what you are doing and have a very recent MRI of the brain and the spine you shouldn't rush into sticking needles in them.

 

[Planktonmd]

1. Obstruction: Signs and symptoms-

Blurred or double vision
Cognitive difficulties
Downward gaze or "sun-setting eyes"
Headache
Imbalance and dizziness
Incontinence
Irregular gait
Lethargy
Nausea
Poor coordination
Visual disturbances
Vomiting
Weakness

We could put in a Camino bolt kit or get an opening pressure on LP, but in vivo human studies (clinical situations) this would be unwise.

2. Syrinx- generally accepted that 1-2mm are rarely symptomatic. A syrinx would have to reach such an enormous size that the cord would be obliterated before any epidural encroachment could occur. Think of the dura filled with CSF and no cord, it still would not create an outpouching of the dura.

3. Injectng an epidural volume sufficient to change pressure in the CSF would likely need to be at least 50cc unless there were epidural adhesions limiting the flow of fluid through the epidural space or if hypertonic saline was used.

Claims data:

Half of the 63 nerve injury claims involved spinal cord injury, including 14 epidural steroid injections, six of which resulted in paraplegia and one quadriplegia. Other procedures associated with nerve injury involving the spinal cord included blocks (5), ablative procedures (3), cervical facet (1), implantation or removal of devices (2) and device maintenance (4). There were 18 claims for paraplegia or quadriplegia, and they included epidural abscess (4), chemical injury from injection into the spinal cord (8) and epidural hematoma (4). Other nerve injury claims included the lumbosacral nerve root (21), the sciatic nerve (2) and the brachial plexus (2).

There were 59 claims for pneumothorax, 40 of which were associated with blocks and 18 from injections, predominantly trigger-point injections. More than half (34) of the patients were diagnosed with pneumothorax after they had been discharged, and of these, 15 patients were diagnosed and treated in an emergency room.

Infection accounted for 13 percent of all claims from invasive procedures. Most were associated with epidural steroid injections and some with implantation, removal or maintenance of implanted devices. Meningitis (12) was the most common presentation followed by epidural abscess (7) and osteomyelitis (3). Surgical intervention was required in six of the seven epidural abscesses with one patient sustaining permanent neurological deficits.

Claims for death or brain damage were associated with epidural steroid injections (9) and device maintenance (9). Of the 114 claims related to epidural steroid injections, 61 of the injections used local anesthetics and or opioids. All nine epidural steroid injections resulting in death or brain damage contained local anesthetics with or without opioids [Figure 2]. Events include unintended intrathecal injection (5), allergic reaction (1), cardiovascular collapse and respiratory depression from inadvertent intrathecal injection at the thoracic level (1), and delayed respiratory depression from epidural morphine administered with the steroid (3).

4. Epidurals and syrinx occur this way: http://medpics.findlaw.com/enlargeexhibit.php?ID=13490

I'm such a PITA. mil already capped this argument.

So what is your point?
Should we just go ahead and stick epidurals and spinals in these patients because your personal opinion is that anything less than 50 cc in the epidural space is not going to change ICP?
And because you personally promised us that wet taping someone who has a chiari malformation is ok?

 

[Planktonmd]

OK,
I am done with this stupid thread.
Merry christmas all.

 

[militarymd]

this thread is not stupid....it shows point & counterpoint.

It makes people think about what & why we do things....its made me think about something I have not thought about in a while.

 

[SexPanther]

I think you guys are wrong about this one. Chiari I is not benign. Im not sure about this particular case, but syringomyelia and symptoms are certainly possibilities.

Yes, completely wrong. How do I know? I had a type I Chiari malformation diagnosed at the age of 20. Headaches all day every day with yolk-like anesthesia. What caused that? My syringomyelia did. Got the Chiari decompressed with a C1 laminectomy and insertion of a dural patch, but my neurosurgeon wasn't able to get the syrinx to drain. The operation fueled my switch to pre-medicine the summer before my senior year of undergrad. G*damn chiari!!

 

[militarymd]

Yes, completely wrong. How do I know? I had a type I Chiari malformation diagnosed at the age of 20. Headaches all day every day with yolk-like anesthesia. What caused that? My syringomyelia did. Got the Chiari decompressed with a C1 laminectomy and insertion of a dural patch, but my neurosurgeon wasn't able to get the syrinx to drain. The operation fueled my switch to pre-medicine the summer before my senior year of undergrad. G*damn chiari!!

well you're ok ...right? I define that as benign..

headaches are annoying, but they ARE benign

 

[urge]

well you're ok ...right?

I bet he is a Funny Looking Kid...

 

[seinfeld]

OK,
I am done with this stupid thread.
Merry christmas all.

Sorry, i thought it was a rather good topic. In fact i am glad others disagreed with you it created quite a good discourse on the +/-'s... exactly what i had hoped for.

merry christmas

 

[SexPanther]

I bet he is a Funny Looking Kid...

Nah, I'm one sexy mofo.

 

[lobelsteve]

So what is your point?
Should we just go ahead and stick epidurals and spinals in these patients because your personal opinion is that anything less than 50 cc in the epidural space is not going to change ICP?
And because you personally promised us that wet taping someone who has a chiari malformation is ok?

If you practice the standard of care, folks like me will come to testify that you practiced the standard or care. For the right price.😀

If you are testiculating, by all means keep it going....just do not get the folks who think they can learn something useful on this forum caught in the web.

 

[Planktonmd]

If you practice the standard of care, folks like me will come to testify that you practiced the standard or care. For the right price.😀

If you are testiculating, by all means keep it going....just do not get the folks who think they can learn something useful on this forum caught in the web.

Now you are making me curious:
What makes someone like you think that you can be an expert on anesthesia?
Is it because you do epidurals (or you claim you do) that you suddenly feel that you are entitled to give opinions on anesthesiology?
How many labor epidurals have you done in your career?
I wish people would recognize the limitations of their training before infringing on other specialties.
I did not want to continue posting to this thread but you are beyond irritating.

 

[lobelsteve]

Now you are making me curious:
What makes someone like you think that you can be an expert on anesthesia?
Is it because you do epidurals (or you claim you do) that you suddenly feel that you are entitled to give opinions on anesthesiology?
How many labor epidurals have you done in your career?
I wish people would recognize the limitations of their training before infringing on other specialties.
I did not want to continue posting to this thread but you are beyond irritating.

I said folks like me, not me. I can speak of the anatomy, epidural injections, and complications thereof. I know little about anesthesia, and I am glad docs like you are willing to work for and in hospitals. My family is too important to me to spend my days working anywhere I did not have complete control over my schedule. 8-4 MF, No weekends, no holidays, no call. And I am quite content with my choices.

Prefacing posts with, I think this is a bad idea because or, in my opinion, or this would appear to be the best answer.... would make you seem like a much more caring and concerned individual. Literature is a wonderful tool.
If you want the reference for volume in the epidural space..Pappagallo p438 Neurological Basis of Pain.








These forums can be a useful learning tool, and insistance or pressing a point that is not valid deserves derision. It is how we police ourselves and our facts.

 

[Idiopathic]

I bet he is a Funny Looking Kid...

this is, in fact, comepletely true

 

[Planktonmd]

I said folks like me, not me. I can speak of the anatomy, epidural injections, and complications thereof. I know little about anesthesia, and I am glad docs like you are willing to work for and in hospitals. My family is too important to me to spend my days working anywhere I did not have complete control over my schedule. 8-4 MF, No weekends, no holidays, no call. And I am quite content with my choices.

Prefacing posts with, I think this is a bad idea because or, in my opinion, or this would appear to be the best answer.... would make you seem like a much more caring and concerned individual. Literature is a wonderful tool.
If you want the reference for volume in the epidural space..Pappagallo p438 Neurological Basis of Pain.









These forums can be a useful learning tool, and insistance or pressing a point that is not valid deserves derision. It is how we police ourselves and our facts.

Listen,
My point is not invalid, actually I can assure you that the majority of practicing anesthesiologists would agree with me and would not do neuraxial anesthesia on someone with chiari malformation.
Your input was completely out of context and irrelevant, and let me tell something about the effect of volume injected in the epidural space on ICP:
When I do blood patches on patients who had epidural injections by people like you the headache disappears after 15 - 20 CC, this means the ICP had increased, can you grasp this concept?
We deal with a patient population you are not familiar with under conditions beyond your level of expertise.
One more thing, No one asked you why you became a glorified physical therapist and not an anesthesiologist so you didn't really need to tell us your life story.

 

[urge]

/thread

 

[SexPanther]

this is, in fact, comepletely true

Now we must cage fight.

 

[lobelsteve]

Listen,
My point is not invalid, actually I can assure you that the majority of practicing anesthesiologists would agree with me and would not do neuraxial anesthesia on someone with chiari malformation.
Your input was completely out of context and irrelevant, and let me tell something about the effect of volume injected in the epidural space on ICP:
When I do blood patches on patients who had epidural injections by people like you the headache disappears after 15 - 20 CC, this means the ICP had increased, can you grasp this concept?
We deal with a patient population you are not familiar with under conditions beyond your level of expertise.
One more thing, No one asked you why you became a glorified physical therapist and not an anesthesiologist so you didn't really need to tell us your life story.

I perform epidural procedures including adhesiolyis with either Myelotec or EBI-Target catheters several times per year. In patients with Chiari I and post laminectomy syndrome, I have yet to see a CSF leak or neurological compromise. My N=3 or 4. Many Chairi I patients are undiagnosed and asymptomatic. So with my tiny N and no issues, I'm awaiting a response by somebody who has had compromise or who can postulate a reasonable argument that entering the epidural space in these patients can be more dangerous than in the general population.


PUBMED is your friend:

Beverly J. Newhouse1 and Krzysztof M. Kuczkowski1

(1) Department of Anesthesiology, UCSD Medical Center, 200 W. Arbor Drive, San Diego, CA 92103-8770, USA

Received: 4 July 2006 Accepted: 15 July 2006 Published online: 16 August 2006

Abstract Arnold-Chiari malformation is a disorder of the hindbrain which can lead to altered craniospinal pressures and abnormal flow of cerebrospinal fluid. The possibility of increased intracranial pressure imparts significant risk during labor and delivery, and has led to concern over the use of neuraxial anesthesia. Sickle cell disease is a disorder of abnormal hemoglobin that is prone to sickling under stressful conditions. The physiologic and metabolic changes associated with pregnancy and labor can precipitate sickling, which increases risks for both the mother and the fetus. Vaso-occlusive pain crisis in a parturient with sickle cell disease has been shown to improve with the initiation of neuraxial anesthesia. We present the first reported case of a parturient with both Arnold-Chiari malformation type I and sickle cell disease who presented to labor and delivery with acute pain crisis and who subsequently received epidural labor analgesia and underwent successful vaginal delivery. We include a discussion of the risks associated with pregnancy, labor, neuraxial anesthesia, and delivery in a patient with Arnold-Chiari malformation type I and sickle cell disease.


Thanks for the insult. I guess you are always right.
Please reference the increased ICP after blood patch. I would agree that ICP increases, but only to reach baseline. Normal range 80-180 mmH2O, so with PDPH is the pressure 40? If you perform a blood patch does the pressure then exceed 180?

Let me bask in the glory of your knowledge.

COLOR="Red"]The debasing of your character is an unpleasant way of presenting yourself in an open forum. Stick to the facts and the case, I am certain you are a much finer person than I am; probably richer, taller, happier, and providing a higher standard of care for your patients and the country than I could provide. I have nothing bad to say, but thanks for the personal attack on my profession, skill, character, and intelligence. I must now travel to NJ to cry on my mothers shoulder.[/COLOR}

1 Sicuranza GB, Steinberg T, Figueroa R. Arnold-Chiari malformation in a pregnant woman. Obstet Gynecol 2003; 102 (5 Pt 2): 1191–4.[Abstract/Free Full Text]

2 Heiss JD, Patrons N, DeVroom HT, et al. Elucidating the pathophysiology of syringomyelia. J Neurosurg 1999; 91: 553–62.[Medline]

3 Semple DA, McClure JH. Arnold-Chiari malformation in pregnancy. Anaesthesia 1996; 51: 580–2.[Medline]

4 Landau R, Giraud R, Delrue V, Kern C. Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiari malformation. Anesth Analg 2003; 97: 253–5.[Abstract/Free Full Text]

5 Hullander RM, Bogard TD, Leivers D, Moran D, Dewan DM. Chiari I malformation presenting as recurrent spinal headache. Anesth Analg 1992; 75: 1025–6.[Free Full Text]

Now I have to get back to work creating more patients who require blood patches.....

 

[Planktonmd]

I perform epidural procedures including adhesiolyis with either Myelotec or EBI-Target catheters several times per year. In patients with Chiari I and post laminectomy syndrome, I have yet to see a CSF leak or neurological compromise. My N=3 or 4. Many Chairi I patients are undiagnosed and asymptomatic. So with my tiny N and no issues, I'm awaiting a response by somebody who has had compromise or who can postulate a reasonable argument that entering the epidural space in these patients can be more dangerous than in the general population.


PUBMED is your friend:

Beverly J. Newhouse1 and Krzysztof M. Kuczkowski1

(1) Department of Anesthesiology, UCSD Medical Center, 200 W. Arbor Drive, San Diego, CA 92103-8770, USA

Received: 4 July 2006 Accepted: 15 July 2006 Published online: 16 August 2006

Abstract Arnold-Chiari malformation is a disorder of the hindbrain which can lead to altered craniospinal pressures and abnormal flow of cerebrospinal fluid. The possibility of increased intracranial pressure imparts significant risk during labor and delivery, and has led to concern over the use of neuraxial anesthesia. Sickle cell disease is a disorder of abnormal hemoglobin that is prone to sickling under stressful conditions. The physiologic and metabolic changes associated with pregnancy and labor can precipitate sickling, which increases risks for both the mother and the fetus. Vaso-occlusive pain crisis in a parturient with sickle cell disease has been shown to improve with the initiation of neuraxial anesthesia. We present the first reported case of a parturient with both Arnold-Chiari malformation type I and sickle cell disease who presented to labor and delivery with acute pain crisis and who subsequently received epidural labor analgesia and underwent successful vaginal delivery. We include a discussion of the risks associated with pregnancy, labor, neuraxial anesthesia, and delivery in a patient with Arnold-Chiari malformation type I and sickle cell disease.


Thanks for the insult. I guess you are always right.
Please reference the increased ICP after blood patch. I would agree that ICP increases, but only to reach baseline. Normal range 80-180 mmH2O, so with PDPH is the pressure 40? If you perform a blood patch does the pressure then exceed 180?

Let me bask in the glory of your knowledge.

COLOR="Red"]The debasing of your character is an unpleasant way of presenting yourself in an open forum. Stick to the facts and the case, I am certain you are a much finer person than I am; probably richer, taller, happier, and providing a higher standard of care for your patients and the country than I could provide. I have nothing bad to say, but thanks for the personal attack on my profession, skill, character, and intelligence. I must now travel to NJ to cry on my mothers shoulder.[/COLOR}

1 Sicuranza GB, Steinberg T, Figueroa R. Arnold-Chiari malformation in a pregnant woman. Obstet Gynecol 2003; 102 (5 Pt 2): 1191–4.[Abstract/Free Full Text]

2 Heiss JD, Patrons N, DeVroom HT, et al. Elucidating the pathophysiology of syringomyelia. J Neurosurg 1999; 91: 553–62.[Medline]

3 Semple DA, McClure JH. Arnold-Chiari malformation in pregnancy. Anaesthesia 1996; 51: 580–2.[Medline]

4 Landau R, Giraud R, Delrue V, Kern C. Spinal anesthesia for cesarean delivery in a woman with a surgically corrected type I Arnold Chiari malformation. Anesth Analg 2003; 97: 253–5.[Abstract/Free Full Text]

5 Hullander RM, Bogard TD, Leivers D, Moran D, Dewan DM. Chiari I malformation presenting as recurrent spinal headache. Anesth Analg 1992; 75: 1025–6.[Free Full Text]

Now I have to get back to work creating more patients who require blood patches.....

We see patients who are in acute pain, moving around on the labor floor and we have 3 minutes to make the best clinical decision.
Most often we don't have any diagnostic studies available and most of our patients are not good historians.
You can gather all the case reports and the articles about the subject as you already did, this only shows that there are only sporadic adventurous people who did neueaxial anesthesia on laboring women with Chiari malformation and got away with it, it does not make it a safe practice.
This was not a personal attack on you, this is just a simple statement that you don't have the expertise to contribute to this subject.
But you can take it anyway you like.

 

[militarymd]

Let's look at this subject from outside the box.....which unfortunately many of us (physicians) never do...



Why is it unsafe to perform neuraxial anesthesia for these patients?

Show me the reports of people herniating and dying from a block.

I don't have to show anyone the reports of people getting blocks safely....we've all read them.

However, where are the reports that show that it is unsafe......The "myth" is that it is unsafe, because at some point during one's training, someone told you it was unsafe...and for some reason, most people accept certain things to be true at certain points in their training, and NEVER change from that point on.

 

[coprolalia]

The "myth" is that it is unsafe, because at some point during one's training, someone told you it was unsafe...and for some reason, most people accept certain things to be true at certain points in their training, and NEVER change from that point on.

Okay, what about in a pregnant MS patient undergoing primary c-section? Spinal, or not?

-copro

 

[militarymd]

Okay, what about in a pregnant MS patient undergoing primary c-section? Spinal, or not?

-copro

show me the data that shows why we shouldn't do it.

 

[urge]

Okay, what about in a pregnant MS patient undergoing primary c-section? Spinal, or not?

-copro

I think that deserves another thread.

 

[urge]

Let's look at this subject from outside the box.....which unfortunately many of us (physicians) never do...



Why is it unsafe to perform neuraxial anesthesia for these patients?

Show me the reports of people herniating and dying from a block.

I don't have to show anyone the reports of people getting blocks safely....we've all read them.

However, where are the reports that show that it is unsafe......The "myth" is that it is unsafe, because at some point during one's training, someone told you it was unsafe...and for some reason, most people accept certain things to be true at certain points in their training, and NEVER change from that point on.

I cannot agree more. If theory was of any value in medicine, we wouldn't need clinical trials. But the truth is we need clinical trials and theory does not mean much.

 

[VentdependenT]

Okay, what about in a pregnant MS patient undergoing primary c-section? Spinal, or not?

-copro

Good question. Never really had to think about it. Seems like its ok. However there is a slight risk of relapse with ANY anesthetic technique.

http://books.google.com/books?id=TZ...qiU&sig=J8z5OjnCXkQa1uppWUWYDmRGR1w#PPA487,M1