Chiari I malformation

[Planktonmd]

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?

.

It's unsafe because if you create a sudden drop in ICP you can cause more herniation.
It's unsafe because in the presence of Syrinx if you increase the CSF pressure by injecting local in the epidural space you could compromise the cord (and it doesn't take 50 cc).
It's unsafe because if a Syrinx is diagnosed later they will accuse you of creating it by inuring the cord.
It's unsafe because in OB anesthesia you usually don't have the luxury of time and full diagnostic workup to determine that it is safe to proceed.
All these things I mentioned might be theoretical but the majority of practicing anesthesiologists believe in them.

---

Members don't see this ad.

 

[Planktonmd]

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.

There is no "clinical trials" on Neuraxial anesthesia in laboring women who have chiari malformation, and until such data is available we have to use common sense and "theory".
If you think that "theory does not mean much" maybe you should practice nursing.

 

[militarymd]

It's unsafe because if you create a sudden drop in ICP you can cause more herniation.
It's unsafe because in the presence of Syrinx if you increase the CSF pressure by injecting local in the epidural space you could compromise the cord (and it doesn't take 50 cc).
It's unsafe because if a Syrinx is diagnosed later they will accuse you of creating it by inuring the cord.
It's unsafe because in OB anesthesia you usually don't have the luxury of time and full diagnostic workup to determine that it is safe to proceed.
All these things I mentioned might be theoretical but the majority of practicing anesthesiologists believe in them.

Show me ONE single case report of something bad happening from an epidural.

You sound like all of my old, useless professors who can't find a job anywhere else except academia where they enjoy swilling coffee all day long with their donuts and dropping the crumbs on their scrubs which are stretched taut over round bellies like the pregnant ladies who they deny epidurals to because of "myth"s that they perpetuate to residents who don't know any better.

 

[militarymd]

There is no "clinical trials" on Neuraxial anesthesia in laboring women who have chiari malformation, and until such data is available we have to use common sense and "theory".
If you think that "theory does not mean much" maybe you should practice nursing.

The "theory" until 2000 or so was that beta blockade was contraindicated in patients with Low EF's because "it made sense"...

Come on...think outside the box....you are being so "cookie cutter" in your lack of thinking.

Do you have any idea how many people died because their physicians withheld beta blockers because their EF's were low?

You are regurgitating "myth"s that have been shoveled down your throat when you were a resident and didn't know any better....

Not only are you not thinking, the so called "theories" that you are regurgitating do NOT make any physiologic sense....read my above explanations on pressure dynmics in the central nervous system.

And lastly...insulting nurses only makes you look EVEN more ridiculous.

 

[Planktonmd]

The "theory" until 2000 or so was that beta blockade was contraindicated in patients with Low EF's because "it made sense"...

Come on...think outside the box....you are being so "cookie cutter" in your lack of thinking.

Do you have any idea how many people died because their physicians withheld beta blockers because their EF's were low?

You are regurgitating "myth"s that have been shoveled down your throat when you were a resident and didn't know any better....

Not only are you not thinking, the so called "theories" that you are regurgitating do NOT make any physiologic sense....read my above explanations on pressure dynmics in the central nervous system.

And lastly...insulting nurses only makes you look EVEN more ridiculous.

So what are you suggesting with your revolutionary out of the box thinking?
Should the residents go ahead and stick needles in these patients because you think it's the out of the box thing to do based on your opinion that you just formulated 2 days ago when you looked up the malformation on the internet?
A word for the residents:
The fact that I am the only one advocating caution with these cases here on this forum does not mean this is how it is in the real world, actually most practicing anesthesiologists agree with my view, so ask around and form your own opinions.
And by the way: Beta blockers in heart failure are way older the 2000, and the trials on Cavidalol were in 1994.

 

[militarymd]

So what are you suggesting with your revolutionary out of the box thinking?
Should the residents go ahead and stick needles in these patients because you think it's the out of the box thing to do based on your opinion that you just formulated 2 days ago when you looked up the malformation on the internet?
A word for the residents:
The fact that I am the only one advocating caution with these cases here on this forum does not mean this is how it is in the real world, actually most practicing anesthesiologists agree with my view, so ask around and form your own opinions.
And by the way: Beta blockers in heart failure are way older the 2000, and the trials on Cavidalol were in 1994.

I'm just suggesting that dogma and myths are just that...see the other thread...staying inside the box leads to stagnation and poor patient care.

I'm still waiting for that ONE SINGLE case report of something bad happening.

You aren't advocating caution. You are advocating "dogma" as perpetuated by people who are stuck in the box.


Package insert for Lopressor did not change until around year 2000....but bottom line....there are STILL anesthesiologists out there who are teaching that beta blockers are bad in low EFs....

At some point in time, we (physicians) need to accept that what we do is current or up to date...or even correct...just because that's what you were taught.

 

[Planktonmd]

I'm still waiting for that ONE SINGLE case report of something bad happening.

I am still waiting for one real clinical trial showing that it is safe.!

 

[Planktonmd]

Package insert for Lopressor did not change until around year 2000....but bottom line.....

What's up with you and package inserts?
You are the only one I know who actually read the package insert on Oral aiways for example!
This is not "out of the box" thinking!

 

[militarymd]

I am still waiting for one real clinical trial showing that it is safe.!

You are straying from the premise of this discussion.

There are mulitple reports on PubMed that shows that it is safe......There are NONE that shows that it is unsafe.....

and yet you persist with your belief...why?

You and I were both taught the same thing in medical school and residency.

We were both taught a lot of stuff that was never substantiated.

This is one of those subjects....a lot of people saying that it is "unsafe"...and yet when you examine what's out there on PubMed, what do you find?

Lots of little reports saying that it is safe.

No data saying that it is unsafe.

Based on what is reported, how can anyone, as an educated physician, believe that it is that unsafe.

 

[Planktonmd]

You are straying from the premise of this discussion.

There are mulitple reports on PubMed that shows that it is safe......There are NONE that shows that it is unsafe.....

and yet you persist with your belief...why?

You and I were both taught the same thing in medical school and residency.

We were both taught a lot of stuff that was never substantiated.

This is one of those subjects....a lot of people saying that it is "unsafe"...and yet when you examine what's out there on PubMed, what do you find?

Lots of little reports saying that it is safe.

No data saying that it is unsafe.

Based on what is reported, how can anyone, as an educated physician, believe that it is that unsafe.

Because evidence based medicine is based on controled clinical trials not case reports.

 

[militarymd]

Because evidence based medicine is based on controled clinical trials not case reports.

that is correct...so what does one do in the absence of Grade A evidence?

You go with Grade B evidence.....in the absence of Grade B....you go with C....and down the ladder to you go until you reach "case reports" and "series" which is one step above "expert opinion".

You are basing your opinion on No evidence...why? when there is some evidence.

Your opinion is based on NO, ZERO, NADA data......why?

 

[Planktonmd]

that is correct...so what does one do in the absence of Grade A evidence?

You go with Grade B evidence.....in the absence of Grade B....you go with C....and down the ladder to you go until you reach "case reports" and "series" which is one step above "expert opinion".

You are basing your opinion on No evidence...why? when there is some evidence.

Your opinion is based on NO, ZERO, NADA data......why?

Case reports are not evidence, they are equivalent to your grandma's bed time stories.
I can give you examples on very weird case reports about very peculiar things all over the medical literature, no one considers them evidence.
also how can you consider case reports evidence when the total number available does not exceed 2 or 3?
I would take expert opinion over that type of evidence anytime of the day.

 

[militarymd]

Case reports are not evidence, they are equivalent to your grandma's bed time stories.
I can give you examples on very weird case reports about very peculiar things all over the medical literature, no one considers them evidence.
also how can you consider case reports evidence when the total number available does not exceed 2 or 3?
I would take expert opinion over that type of evidence anytime of the day.

I'm glad that you have your own grading system on the "levels of evidence"...unfortunately for you, the rest of us have an accepted, peer reviewed, "levels of evidence" where "expert opinion" is at the VERY bottom.

 

[militarymd]

The above slide comes from an article that theresa horlocker from mayo clinic wrote in A&A.

 

[SouthSideSteve]

What's up with you and package inserts?
You are the only one I know who actually read the package insert on Oral aiways for example!

Because mil is asian he finishes his Sodoku before hes done with induction. He has to have something to entertain him during the case and package inserts are handy.

 

[militarymd]

Because mil is asian he finishes his Sodoku before hes done with induction. He has to have something to entertain him during the case and package inserts are handy.

 

[coprolalia]

Just to clarify, case reports are not case series.

A case series is, for example, one surgeon doing, say, 30 types of the same procedure in a similar patient population then reporting his outcomes.

A case report, like often reported in journals like NEJM (etc.), is usually just a solitary and extreme zebra that's pretty weird.

One case report I remember that I thought was really interesting was a guy who got a prostate tumor in his rib cage after being transplanted by a heart from a guy who died with unknown metastatic prostate cancer. I don't think you can draw a lot of meaningful practice guidance from such cases, but they do make you think.

-copro

 

[zippy2u]

For what its worth about a year ago, I had a 20s lady on OB floor requesting an epidural and was told by the OB doc that she had a chiari malformation. Foreign to my a$$ at the time. She even had her neurologist's home phone # in New York so I called him and he said an epidural would be OK but not to get a wet tap. I told her her big brain guy said an epidural would be OK who she trusted with her life. BANG! she had her epidural in 5 minutes and she was a happy camper. I was workin' with a rookie CRNA at the time and just decided to put the epidural in myself as this chiari thing would have got him all ape$hit. She stalled later that evening and the CRNA just dosed the epidural up and they sectioned her. She did fine. The CRNA wanted to write this all up and put it in his journal. I told he could but not to put my name on the paper. He thought that was unusual and I told him it would be a lot of work and nobody's goin' to pay ya for it. Just chalk it up as another day in the trenches. Run silent...run deep--- as the navy nuclear gurus say. Regards, ---Zip

 

[Planktonmd]

I'm glad that you have your own grading system on the "levels of evidence"...unfortunately for you, the rest of us have an accepted, peer reviewed, "levels of evidence" where "expert opinion" is at the VERY bottom.

You are trying to confuse case reports with case series to prove a point that you couldn't prove.
It's funny that you suddenly know the literature about Chiari malformation although 3 days ago you didn't even know there was Syringomyelia involved!
There are 3-4 sporadic case reports about pregnant women with the malformation getting neuraxial anesthesia, that's all!
Now you can believe whatever your ego allows you to believe but the facts are the facts:
This is uncharted waters and caution is required, that's all!

 

[militarymd]

You are trying to confuse case reports with case series to prove a point that you couldn't prove.
It's funny that you suddenly know the literature about Chiari malformation although 3 days ago you didn't even know there was Syringomyelia involved!
There are 3-4 sporadic case reports about pregnant women with the malformation getting neuraxial anesthesia, that's all!
Now you can believe whatever your ego allows you to believe but the facts are the facts:
This is uncharted waters and caution is required, that's all!

yep, I forgot about the syrinyx association with type I....I educated myself on it and moved on. That's what we do..CME.

you on the other hand...well...

In any case, the data is not high grade. No one ever said that it was.

However, you have no data at all.

 

[Planktonmd]

yep, I forgot about the syrinyx association with type I....I educated myself on it and moved on. That's what we do..CME.

you on the other hand...well...

In any case, the data is not high grade. No one ever said that it was.

However, you have no data at all.

No,
I have common sense and expert opinions you have fairy tales and case reports.

 

[urge]

Has anyone had a chance to check what "Anesthesia & uncommon disease", or any similar book, says about the subject?

Me=poor cannot afford such big books.

Plankton, let's say you were in zippy's shoes and the neurologist tells you it's ok for her to get an epidermal. Would you change your mind or not?

 

[Planktonmd]

Has anyone had a chance to check what "Anesthesia & uncommon disease", or any similar book, says about the subject?

Me=poor cannot afford such big books.

Plankton, let's say you were in zippy's shoes and the neurologist tells you it's ok for her to get an epidermal. Would you change your mind or not?

No, because he said do it but make sure you don't get a wet tap!
There is no such certainty in medicine and things you are trying to avoid end up happening.
He can't say it's OK but if you wet tap her it's your problem.
On the other hand If he provided a written consult stating that the ICP is not elevated and there is no evidence of major syringomyelia according to current studies and that he doesn't see a contraindication to either spinal or epidural anesthesia and if the clinical picture correlated with his recommendations then I would be happy to do it.

 

[urge]

Plank,

Do you do thoracic epidurals?

 

[Planktonmd]

Plank,

Do you do thoracic epidurals?

I don't understand your question:
Do I do thoracic epidurals for labor or do I do thoracic epidurals in general?
For labor I do lumbar epidurals but there were times when I had to go as high as L1 L2 or even T12 L1 because the patient was really morbidly obese and I couldn't do it lower.
By the way Syrinx formation can be lumbar in Chiari malformation.

 

[urge]

When you do thoracic epidural you CANNOT(you can, but you'll be in deep doodoo) wet tap the patient. This does not stop us from doing them.

Sounds similar to this scenario. So, why do one and not the other?

 

[militarymd]

I don't understand your question:
Do I do thoracic epidurals for labor or do I do thoracic epidurals in general?
For labor I do lumbar epidurals but there were times when I had to go as high as L1 L2 or even T12 L1 because the patient was really morbidly obese and I couldn't do it lower.
By the way Syrinx formation can be lumbar in Chiari malformation.

Dude,

I CANNOT believe that you were one of Steadman's residents.

 

[Planktonmd]

When you do thoracic epidural you CANNOT(you can, but you'll be in deep doodoo) wet tap the patient. This does not stop us from doing them.

Sounds similar to this scenario. So, why do one and not the other?

You never want to wet tap any patient but **** happens!
If you haven't wet tapped a thoracic epidural yet this means you haven't done enough, you will eventually see it and most likely nothing will happen because usually people tend to stop when they see CSF and they rarely feel the need to shove the needle deeper.
I have seen thoracic wet taps and cervical wet taps as well, and luckily non of them caused a disaster to my knowledge.
On the other hand if you are doing an epidural on a patient with chiari malformation and you haven't done every effort to make sure that the ICP is not elevated (Which you usually can not do on a typical OB floor) and that there is no significant syringomyelia, then you are taking unnecessary risk in my opinion.

 

[Planktonmd]

Dude,

I CANNOT believe that you were one of Steadman's residents.

Well, she is a cautious and wise clinician above all and I am sure she would carefully measure the risk and benefit before doing any procedure.
I actually can't believe she agreed to be your partner!

 

[militarymd]

Well, she is a cautious and wise clinician above all and I am sure she would carefully measure the risk and benefit before doing any procedure.
I actually can't believe she agreed to be your partner!

She's my assistant chief.


and btw....not one second delay when I asked if she would place a neuraxial anesthetic for this type of patient before saying that it is a "no brainer"....

How does that suit you?

 

[urge]

On the other hand if you are doing an epidural on a patient with chiari malformation and you haven't done every effort to make sure that the ICP is not elevated (Which you usually can not do on a typical OB floor) and that there is no significant syringomyelia, then you are taking unnecessary risk in my opinion.

What do you mean by that? What is acceptable to you?

 

[urge]

[FONT=Arial, Helvetica, sans-serif]From: http://www.anesthesiaweb.com/new_direction/archive/ask/archive_ask_obgyn.shtml

Should a pregnant patient with Arnold-Chiari Malformation Type 1 be allowed to undergo labor and delivery with an epidural, or is it best to schedule an elective C-section under general anesthesia? —[email protected] .

[FONT=Arial, Helvetica, sans-serif]Dr. Peter Dwane responds:.
[FONT=Arial, Helvetica, sans-serif]Arnold-Chiari malformation Type 1 is characterized by the partial descent of the medulla and cerebellar tonsils through the foramen magnum. This malformation carries with it a risk of increased intracranial pressure(ICP), which may be asymptomatic. Cough-induced headache may also bepresent. .
[FONT=Arial, Helvetica, sans-serif]This patient should be assessed by a neurologist or neurosurgeon because this uncommon condition needs to be specifically evaluated. Then there should be discussion among this neuro-specialist, the Obstetrician, and Anesthesiologist. Discussion would likely center around avoiding situationswhich might increase the pressure above the lesion relative to below the lesion… i.e. increasing the ICP with CNS depressants after a general anesthetic, or lowering the spinal pressure with a dural puncture. For the same reason the patient may be better of not bearing down during delivery. There are no series reporting the superiority of one anesthetic technique over another. My initial inclination would be toward general anesthesia for Cesarean section. But the specifics are best worked out by the three specialists involved. .
[FONT=Arial, Helvetica, sans-serif]References:.

1. [FONT=Arial, Helvetica, sans-serif]Nel MR Robson V Robinson PN. Extradural anaesthesia for caesarean section in a patient with syringomyelia and Chiari type I anomaly. British Journal of Anaesthesia. 80(4):512-5, 1998 Apr..
2. [FONT=Arial, Helvetica, sans-serif]Semple DA. McClure JH. Arnold-chiari malformation in pregnancy. Anaesthesia. 51(6):580-2, 1996 Jun..

No mention about labor analgesia, though.

 

[Planktonmd]

She's my assistant chief.


and btw....not one second delay when I asked if she would place a neuraxial anesthetic for this type of patient before saying that it is a "no brainer"....

How does that suit you?

It really depends on what you mean by saying "this type of patient".
A patient with chiari malformation who was never symptomatic and has a recent MRI showing no indirect signs of increased ICP and no significant Syringomyelia combined with the blessing of a Neurologist would be a " No Brainer".

 

[Planktonmd]

[FONT=Arial, Helvetica, sans-serif]From: http://www.anesthesiaweb.com/new_direction/archive/ask/archive_ask_obgyn.shtml.

[FONT=Arial, Helvetica, sans-serif]Should a pregnant patient with Arnold-Chiari Malformation Type 1 be allowed to undergo labor and delivery with an epidural, or is it best to schedule an elective C-section under general anesthesia? —[email protected] .

[FONT=Arial, Helvetica, sans-serif]Dr. Peter Dwane responds:.
[FONT=Arial, Helvetica, sans-serif]Arnold-Chiari malformation Type 1 is characterized by the partial descent of the medulla and cerebellar tonsils through the foramen magnum. This malformation carries with it a risk of increased intracranial pressure(ICP), which may be asymptomatic. Cough-induced headache may also bepresent. .
[FONT=Arial, Helvetica, sans-serif]This patient should be assessed by a neurologist or neurosurgeon because this uncommon condition needs to be specifically evaluated. Then there should be discussion among this neuro-specialist, the Obstetrician, and Anesthesiologist. Discussion would likely center around avoiding situationswhich might increase the pressure above the lesion relative to below the lesion… i.e. increasing the ICP with CNS depressants after a general anesthetic, or lowering the spinal pressure with a dural puncture. For the same reason the patient may be better of not bearing down during delivery. There are no series reporting the superiority of one anesthetic technique over another. My initial inclination would be toward general anesthesia for Cesarean section. But the specifics are best worked out by the three specialists involved. .
[FONT=Arial, Helvetica, sans-serif]References:.

1. [FONT=Arial, Helvetica, sans-serif]Nel MR Robson V Robinson PN. Extradural anaesthesia for caesarean section in a patient with syringomyelia and Chiari type I anomaly. British Journal of Anaesthesia. 80(4):512-5, 1998 Apr..
2. [FONT=Arial, Helvetica, sans-serif]Semple DA. McClure JH. Arnold-chiari malformation in pregnancy. Anaesthesia. 51(6):580-2, 1996 Jun..

No mention about labor analgesia, though.

This is exactly what I was saying.

 

[urge]

This is exactly what I was saying.

This is very conservative. Mostly intended to spread liability between every provider possible. Doesn't really mean it's the right thing to do. I cannot blame you for taking your stance. A lot of people would do the same. But, a lot of people would do different and I don't think you have evidence to prove they are wrong.

 

[militarymd]

It really depends on what you mean by saying "this type of patient".
A patient with chiari malformation who was never symptomatic and has a recent MRI showing no indirect signs of increased ICP and no significant Syringomyelia combined with the blessing of a Neurologist would be a " No Brainer".

nope...the original patient was what she was referring to....and actually...just about any walkie talkie prego patient with arnold chiari was what she was referring to....

If you want, I will ask her again...but she was looking over my shoulder a couple of days ago while I was posting.....

she called me a "dinkus" for arguing with people on the internet.....but called you a "*****"

 

[jetproppilot]

No, because he said do it but make sure you don't get a wet tap!
There is no such certainty in medicine and things you are trying to avoid end up happening.
He can't say it's OK but if you wet tap her it's your problem.
On the other hand If he provided a written consult stating that the ICP is not elevated and there is no evidence of major syringomyelia according to current studies and that he doesn't see a contraindication to either spinal or epidural anesthesia and if the clinical picture correlated with his recommendations then I would be happy to do it.

I respect you, Plank.

You are a valid, important contributor here.

I humbly disagree with your stance here.

My cowboy days are long gone.

But if I avoided procedures and cases because of low-% "what-ifs", I'd have a lot more time to sit in the doctors lounge.

My wet tap rate is exceedingly low, knock on wood. I cant remember the last one that occurred.

So based on my needle driving skill, I would've weighed the risks and benefits of the procedure, and wouldve put the epidural in. Chances are exceedingly rare for a wet tap in experienced hands.

I'm sure you share the same skill I've acquired.....as does Mil, UT, Noy, Zippers, and all the other deft private practice needle drivers.

I choose to practice based on what my skill level is, what outcome studies show, and what I've seen/experienced.

Which is sometimes different than what we learned during our pearly gates academia years.

There is no right answer here.

Just great that we are discussing this to stimulate resident minds.

 

[Planktonmd]

I respect you, Plank.

You are a valid, important contributor here.

I humbly disagree with your stance here.

My cowboy days are long gone.

But if I avoided procedures and cases because of low-% "what-ifs", I'd have a lot more time to sit in the doctors lounge.

My wet tap rate is exceedingly low, knock on wood. I cant remember the last one that occurred.

So based on my needle driving skill, I would've weighed the risks and benefits of the procedure, and wouldve put the epidural in. Chances are exceedingly rare for a wet tap in experienced hands.

I'm sure you share the same skill I've acquired.....as does Mil, UT, Noy, Zippers, and all the other deft private practice needle drivers.

I choose to practice based on what my skill level is, what outcome studies show, and what I've seen/experienced.

Which is sometimes different than what we learned during our pearly gates academia years.

There is no right answer here.

Just great that we are discussing this to stimulate resident minds.

Fair enough.
If you fully understand the issues you are facing and you use your clinical judgment to choose the best available option, this means you ultimately did what you are expected to do: practice medicine.

 

[Noyac]

Well said Jet as usual


Can we close this thread now?

 

[militarymd]

OK...close it after this....

x-mmd >>>>> pp perspective (although my partner is one of plank's attendings)


plankmd >>>>> academic perspective

 

[jetproppilot]

Well said Jet as usual


Can we close this thread now?

As you request.