Dorsal column stimulator and OB anesthesia

[xyzdoc]

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Dear all,

I would like to ask a general question regarding DCS and OB anesthesia. One of our obstetricians mentioned the case but could not provide detailed information. I am trying to research on it before we see the patient.

A pregnant woman who has a dorsal column stimulator for lower extremity CRPS (details unknown at this time) will come for elective vaginal delivery. What are the options for labor analgesia? What if we need to go back for section?

Thanks!

 

[Planktonmd]

Dear all,

I would like to ask a general question regarding DCS and OB anesthesia. One of our obstetricians mentioned the case but could not provide detailed information. I am trying to research on it before we see the patient.

A pregnant woman who has a dorsal column stimulator for lower extremity CRPS (details unknown at this time) will come for elective vaginal delivery. What are the options for labor analgesia? What if we need to go back for section?

Thanks!

IV medications for labor.
GA for C section.

 

[CanGas]

Well you certainly would not want to stick a Touhy through the electrodes or the leads leading to the generator. You also would not what your catheter to displace or become entangled with the electrodes. I am not sure what the theoretical concerns regarding bathing the electrodes in local anesthetic + narcotic mixture are but I can’t think of any particular problems.

Here are a couple images of what they look like.
http://upload.wikimedia.org/wikipedia/en/thumb/1/1c/SCS.jpg/180px-SCS.jpg
http://www.mayfieldclinic.com/Images/PE-Stim_Figure4.jpg

It has been done before. In a quick search I found 3 case reports, one cervical and two lumbar-thorasic as well as an intra-thecal pump. I would have no problems with a cervical stimulator. The lumbar would give me pause.

Given this will be a term baby I think I would talk about getting an AP x-ray of the lumbar-thorasic spine to localize the electrodes and leads. Radiation of a single x-ray dose should be minimal. Or at least copies of the post-op x-rays from the implantation. If I had room to pass the catheter 3-4cm into the space without hitting the stimulator I would have a frank discussion with the patient regarding risks.

Remember, these are chronic pain patients so how well do you really think IV medications are going to work? However, these are chronic pain patients so how well do you really think and adverse event will be tolerated without lawsuit (infection from seeding of foreign body (spinal stimulator), displacement of stimulator leads, ect).

The easy answer is no way. But for a chronic pain patient who is in severe distress, who had a frank discussion of risks (PRIOR to the distress of labor when judgment in unimpaired), I would be willing if I new exactly where the implanted materials were located.

Labor epidural placement in a woman with a cervical spinal cord stimulator. International Journal of Obstetric Anesthesia. Volume 15, Issue 3, July 2006, Pages 246-249

Abstract Title: Epidural Analgesia for Vaginal Delivery in a Parturient with a Lumbothoracic Spinal Cord Stimulator
http://www.asra.com/education/display_spring-2007.php?id=134

J. Tarshis, J.E. Zuckerman, N.P. Katz, S. Segal and P.S. Mushlin, Labour pain management in a parturient with an implanted intrathecal pump, Can J Anaesth 44 (1997), pp. 1278–1281

K.E. Nelson and J.C. Crews, Epidural analgesia for vaginal delivery in a parturient with a spinal cord stimulator, Anesthesiology 100 (2004), p. A113.

 

[Tenesma]

hi

most dorsal columns are implanted at L1/L2 and threaded up to the mid-thoracic spine ...

i would think an epidural is very wise - a chronic pain patient is going to be very unresponsive to IV meds...

most epidurals are placed between L3 and L5 and you rarely advance the catheter beyond 3-5 cm so you shoule be NOWHERE near the SCS catheter... the connecting leads are paraspinal and on the ipsilateral side of the battery (IPG) - so if you go paramedian just make sure that you go contralateral to IPG...

if it was an emergency c-section i would have no prob with a quick spinal...

 

[joshmir]

Abstract Title: Spinal Cord Stimulation and the Pregnant Patient: A Multidisciplinary Approach to Management
Authors: Bernardini D1, Bernardini T2, Simopoulos T3
Beth Israel Deaconess Medical Center1, Beth Israel Deaconess Medical Center2, Beth Israel Deaconess Medical Center3
Poster Type: Poster



ABSTRACT BODY
Introduction: The past 40 years has seen a rapid increase in the technological advancement and scope of conditions amenable to the use of spinal cord stimulators (SCS). Little information exists regarding the management of these devices in patients who later become pregnant. Unfortunately, the unfamiliarity of SCSs among non-pain physicians, particularly within the obstetric and obstetric anesthesiology community, causes concern and an ever increasing number of questions around their use before, during, and after the peripartum period.
Objective: With very little guidance from the FDA, SCS manufacturers, and other pertinent societies and organizations regarding the use and risks of these devices during pregnancy and their management during the peripartum period, no general consensus exists within the medical community. The purpose of this study is to determine if some of these pitfalls can be overcome and questions and concerns answered with a multidisciplinary approach to the management of these patients. Our hope is to ultimately provide some general guidance in order to create a treatment plan to effectively and safely manage these patients’ chronic pain during pregnancy and their acute labor pain during the peripartum period while ensuring the safety of the developing fetus and neonate.
Materials and Methods: We report two female patients with complex regional pain syndrome (CRPS) who received adequate analgesia following SCS implantation and who both later went on to became pregnant and deliver healthy newborns. Due to the conflicting opinions among many clinicians regarding the use of SCS in the pregnant patient, the choice was made to deactivate these devices in both patients until after delivery, with the subsequent return of their pain symptoms early during pregnancy. Many issues and questions arose regarding acute and chronic pain management, labor epidural placement, postpartum analgesia, and fetal and neonatal safety, with very little consensus among the involved specialists. However, based on our experience with these patients during their pregnancies and following a early multidisciplinary discussion among obstetrics, maternal-fetal medicine, obstetric anesthesia, and pain management specialists, the SCS was re-activated at 30-weeks gestation when one of these patients became pregnant a second time.
Results: A multidisciplinary approach to these patients provides a clearer plan during pregnancy and the peripartum period. It ensured adequate analgesia from an effectively operating SCS during pregnancy and a realistic plan for additional analgesia during labor and the postpartum period, if needed, all within the context of a safe environment for the developing fetus and newborn. Furthermore, a clear-cut and well laid plan implemented from the outset generated fewer questions and concerns and provided a greater sense of confidence in the ongoing management of this patient.
Conclusions: A multidisciplinary approach to the management of pregnant patients with SCSs, while obvious in necessity but rarely performed in reality, provides a comfortable pregnancy, labor, and delivery for the mother, a safe environment for the developing fetus and newborn, and a clear and logical plan for the clinicians.

ATTACHED FILES
Reg Anesth Pain Med 2007; 32:A-6

 

[mille125]

hi

most dorsal columns are implanted at L1/L2 and threaded up to the mid-thoracic spine ...

i would think an epidural is very wise - a chronic pain patient is going to be very unresponsive to IV meds...

most epidurals are placed between L3 and L5 and you rarely advance the catheter beyond 3-5 cm so you shoule be NOWHERE near the SCS catheter... the connecting leads are paraspinal and on the ipsilateral side of the battery (IPG) - so if you go paramedian just make sure that you go contralateral to IPG...

if it was an emergency c-section i would have no prob with a quick spinal...

what you say is definitely true...

however, i must say that anesthesia residents and attendings are notoriously lax in sterile technique for neuroaxial procedures....if i placed that SCS, i would not want the anesthesia providers to be anywhere near it...just my preference.....i would tell the patient to consider general...

 

[xyzdoc]

Dear folks, thank you so much for the information. We will set up a consultation with the patient, her pain specialist, and go from there. Again, many thanks!!