Epidural or spinal in patient with Harrington rods.

[Laurel123]

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Hi! Any of you guys ever successfully placed a labor epidural in a patient with Harrington rods? Of course, in the middle of the night, I had a patient who was pregnant for the first time and wanted an epidural. Then surprise, she had had spinal fusion for scoliosis as a teen. No xrays and no records. From the scar on her back it looks like it goes from high thoracic level all the way to the sacral region. And to make matters worse, she has a huge scar at L4-L5 or L3-L5 where she had a postop wound infection. She has a thoractomy incision as well. I told her based on the scar I probably can't find the space, but I gave it a brief, careful try.. Unsuccessful. The studies are limited.

 

[huktonfonix]

wow. that sucks for her. Good thing its an elective procedure. I've never had to try that although I imagine hitting the space would be lucky at best. Maybe a spinal with low dose local/narc if youre lucky enough to get CSF.

 

[Planktonmd]

Hi! Any of you guys ever successfully placed a labor epidural in a patient with Harrington rods? Of course, in the middle of the night, I had a patient who was pregnant for the first time and wanted an epidural. Then surprise, she had had spinal fusion for scoliosis as a teen. No xrays and no records. From the scar on her back it looks like it goes from high thoracic level all the way to the sacral region. And to make matters worse, she has a huge scar at L4-L5 or L3-L5 where she had a postop wound infection. She has a thoractomy incision as well. I told her based on the scar I probably can't find the space, but I gave it a brief, careful try.. Unsuccessful. The studies are limited.

I usually place a low thoracic epidural in these cases ( if the thoracic spine is not involved), you can also place a spinal usually as mentioned above, I wouldn't do anything without X rays available though.
In the case you mentioned (big scar, no X rays) I wouldn't do it.

 

[jetproppilot]

Hi! Any of you guys ever successfully placed a labor epidural in a patient with Harrington rods? Of course, in the middle of the night, I had a patient who was pregnant for the first time and wanted an epidural. Then surprise, she had had spinal fusion for scoliosis as a teen. No xrays and no records. From the scar on her back it looks like it goes from high thoracic level all the way to the sacral region. And to make matters worse, she has a huge scar at L4-L5 or L3-L5 where she had a postop wound infection. She has a thoractomy incision as well. I told her based on the scar I probably can't find the space, but I gave it a brief, careful try.. Unsuccessful. The studies are limited.

Yes.

Have also been unsuccessful.

I would suggest definitely trying, with a caveat being to tell the patient before you start that it may or may not work.

You dont need the x rays.

If you strike out midline, try paramedian.

 

[IceDoc]

Hi! Any of you guys ever successfully placed a labor epidural in a patient with Harrington rods? Of course, in the middle of the night, I had a patient who was pregnant for the first time and wanted an epidural. Then surprise, she had had spinal fusion for scoliosis as a teen. No xrays and no records. From the scar on her back it looks like it goes from high thoracic level all the way to the sacral region. And to make matters worse, she has a huge scar at L4-L5 or L3-L5 where she had a postop wound infection. She has a thoractomy incision as well. I told her based on the scar I probably can't find the space, but I gave it a brief, careful try.. Unsuccessful. The studies are limited.

The epidural space may very well be obliterated(though much less likely than with something like a laminectomy), and you may therefore have more success planning for a spinal catheter (i.e. if you plan for it, it's not an accident).

I would wonder about the risk of infection of her hardware? Anybody have any thoughts? data?

 

[Planktonmd]

Yes.

Have also been unsuccessful.

I would suggest definitely trying, with a caveat being to tell the patient before you start that it may or may not work.

You dont need the x rays.

If you strike out midline, try paramedian.

How would you know without X rays what really is going on with her spine?
Most patients have partial knowledge (or no knowledge at all) of what type of surgery or hardware they got.

 

[Laurel123]

Yes.

Have also been unsuccessful.

I would suggest definitely trying, with a caveat being to tell the patient before you start that it may or may not work.

You dont need the x rays.

If you strike out midline, try paramedian.

Yeah, I did give it a try. After emphasizing to her that there was a definite chance that I would not be successful. Also, I told her that if she felt a lot of pain or discomfort that I would stop. And sort of briefed her on what the studies have shown and about how they are limited. From her back scar and the thoracotomy scar, I guessed it went from the high thoracic spine to the sacral area. A few midline tries and a few paramedian tries, I couldn't advance more than 3 cm without hitting bone or hardware. She did not feel any pain during the procedure, but I decided to stop. I think she eventually opted for C/S with general.

 

[Mman]

I've tried 3 times and been successful twice at getting the epidural in at patients with Harrington rods down through the lumbar spine. One time it was a perfect epidural and the other was kind of patchy but not too bad. We used an ultrasound each time to try to get an idea of which way her spinous processes were pointing and where any hardware is.

I've tried using ultrasound to assist in placing an epidural a couple times and it doesn't really help at all because I find it very hard to get a good image of the dura and ligamentum flavum. But I do think that ultrasound can help image to what degree the spinous processes are rotated (if any) and where the hardware is that you want to avoid.


I think the best thing, though, is to just be honest with the patient that it might be impossible but you will give it a shot if they so desire.

 

[milrisome]

I think most patients with this problem are very understanding that epidurals may not be successful. Some of them don't want you to mess around with their back at all. But epidural or subarachnoid attempts in low lumbar locations are probably fine.

I do worry about going through potentially scarred epidural spaces where the spinal cord is located. I don't know if the protection of feeling ligamentum and loss of resistance are going to be there, so I would avoid procedures in this situation.

 

[Noyac]

Lets say you can't find the epidural space but go ahead and place a spinal catheter. How are you going to minimize her risk of getting a spinal HA?

What are you going to do if she gets a PDPH?

What if she begins to have diplopia, tinnitis,and some nausea and vomiting?

 

[VentdependenT]

I usually place a low thoracic epidural in these cases ( if the thoracic spine is not involved), you can also place a spinal usually as mentioned above, I wouldn't do anything without X rays available though.
In the case you mentioned (big scar, no X rays) I wouldn't do it.

That will cover the sacral portion of the pain? How much do you dose through this? Can/have you use it for section?

I think its a damn good idea and I have had an attending place a T-11 or so for a similar patient (or maybe it was just wicked scoliosis) but I didn't stick around for the whole labor.

 

[jetproppilot]

How would you know without X rays what really is going on with her spine?
Most patients have partial knowledge (or no knowledge at all) of what type of surgery or hardware they got.

How are the xrays gonna change your action? You are looking at the scar. Regardless of the xrays, youre gonna try a midline stick or two followed by a paramedian attempt.

Great if you've got 'em but I wouldnt wait on them or refuse to do the procedure if the x rays were unobtainable. And being that I'm gonna do the procedure with or without the xrays, then the xrays are unnecessary.

 

[milrisome]

Lets say you can't find the epidural space but go ahead and place a spinal catheter. How are you going to minimize her risk of getting a spinal HA?

What are you going to do if she gets a PDPH?

What if she begins to have diplopia, tinnitis,and some nausea and vomiting?

Good question. First of all, I would leave the catheter in for 24 hours after the delivery, as this has been shown to reduce the incidence of PDPH. Also, encourage fluid and caffeine intake. Don't make her stay in bed. This does not help.

If she gets PDPH, obviously I wouldn't try for EBP. Just the usual conservative measures like fluids (oral and IV), caffeine (oral and IV), and analgesics (oral and IV).

If she's symptomatic with diplopia and tinnitus, now you have a real problem. Her CSF pressure is getting low enough to affect her CNS (traction on nerves). I would say get her lying down, keep pushing IV fluids and caffeine, maybe put on an abdominal binder. If this doesn't resolve the neurologic symptoms, I would probably call a neurologist to get some advice (i.e., regarding the feasibility of intrathecal saline infusion).

Am I missing anything?

 

[jetproppilot]

Good question. First of all, I would leave the catheter in for 24 hours after the delivery, as this has been shown to reduce the incidence of PDPH. Also, encourage fluid and caffeine intake. Don't make her stay in bed. This does not help.

If she gets PDPH, obviously I wouldn't try for EBP. Just the usual conservative measures like fluids (oral and IV), caffeine (oral and IV), and analgesics (oral and IV).

If she's symptomatic with diplopia and tinnitus, now you have a real problem. Her CSF pressure is getting low enough to affect her CNS (traction on nerves). I would say get her lying down, keep pushing IV fluids and caffeine, maybe put on an abdominal binder. If this doesn't resolve the neurologic symptoms, I would probably call a neurologist to get some advice (i.e., regarding the feasibility of intrathecal saline infusion).

Am I missing anything?

Yes.

The point of Noyac's post.

 

[Planktonmd]

How are the xrays gonna change your action? You are looking at the scar. Regardless of the xrays, youre gonna try a midline stick or two followed by a paramedian attempt.

Great if you've got 'em but I wouldnt wait on them or refuse to do the procedure if the x rays were unobtainable. And being that I'm gonna do the procedure with or without the xrays, then the xrays are unnecessary.

For me X rays make a big difference because I try to stay away from the hardawre if I can, and the scar is not going to tell you the exact level of the rods.

 

[Noyac]

Good question. First of all, I would leave the catheter in for 24 hours after the delivery, as this has been shown to reduce the incidence of PDPH. Also, encourage fluid and caffeine intake. Don't make her stay in bed. This does not help.

If she gets PDPH, obviously I wouldn't try for EBP. Just the usual conservative measures like fluids (oral and IV), caffeine (oral and IV), and analgesics (oral and IV).

If she's symptomatic with diplopia and tinnitus, now you have a real problem. Her CSF pressure is getting low enough to affect her CNS (traction on nerves). I would say get her lying down, keep pushing IV fluids and caffeine, maybe put on an abdominal binder. If this doesn't resolve the neurologic symptoms, I would probably call a neurologist to get some advice (i.e., regarding the feasibility of intrathecal saline infusion).

Am I missing anything?

OK so we went ahead and did it and the PDPH occurred. Your spot on with your management as far as I can tell.

If I did this epidural and she had symptoms like I described then I would want to resolve them. If everything you said didn't work I would attempt a blood patch under flouro. What harm can I do? She already has a PDPH with neurologic symptoms.

PS: I am not saying that I wouldn't do the epidural for labor in the first place.

 

[milrisome]

Yes.

The point of Noyac's post.

Ouch. Ok, I'm sure I deserved that. But if you're going to try epidural at all, you've got to accept the possibility of dural (or more appropriately arachnoid) puncture. So either you don't use a tuohy needle at all and just do repeated intrathecal injections with a pencil point needle every 1.5 hours, or you use a tuohy to attempt an epidural and be ready to deal with the eventual possibility of dural puncture.

Or skip the regional altogether and use a remi PCA.

 

[jetproppilot]

Ouch. Ok, I'm sure I deserved that. But if you're going to try epidural at all, you've got to accept the possibility of dural (or more appropriately arachnoid) puncture. So either you don't use a tuohy needle at all and just do repeated intrathecal injections with a pencil point needle every 1.5 hours, or you use a tuohy to attempt an epidural and be ready to deal with the eventual possibility of dural puncture.

Or skip the regional altogether and use a remi PCA.

No, bro.

I think the argument was....your Tuohy cant find the epidural space so you intentionally punch it in for a spinal catheter.

Which is something I wouldnt do.

And I dont think Noy would either, which was the point of his post.

Finding the subarachnoid space unintentionally is rare in trained hands. Very rare. Happens, but rare.

I'd try for the epidural.

And would quit if I couldnt get it.

No spinal catheter in this pt for me.

 

[epidural man]

Or skip the regional altogether and use a remi PCA.

It looks like you were joking, but I think a remi PCA is a very reasonable and potentially a great solution to this problem. I would love to see it tried.

How about single shot caudals in this or similar patients?

 

[VentdependenT]

I have no experience with caudals in adults. I'd be afraid of an intrathecal injection though...and infection with all that crud hanging down in that general vacinity.

 

[epidural man]

I have no experience with caudals in adults. I'd be afraid of an intrathecal injection though...and infection with all that crud hanging down in that general vacinity.

I've done a ton of caudul steroid shots in the pain clinic. They are easy to do and lower risk than a regular epidural for a dural puncture. I was just wondering if you could do the same in a laboring women with some bupivicaine.

 

[Planktonmd]

I've done a ton of caudul steroid shots in the pain clinic. They are easy to do and lower risk than a regular epidural for a dural puncture. I was just wondering if you could do the same in a laboring women with some bupivicaine.

Yes you can, and many older anesthesiologists used to do it regularly. It's very rare now.
Take a look at this:

http://www.asahq.org/Newsletters/1998/03_98/Epidural_0398.html

 

[Unconscious]

Had a patient with Harrington Rod for repeat C/S, tried for spinal couldn't get it after 2 tries, then I got the U/S machine, scanned L5-S1 (since its the largest space) drew the intercepts of spinous processes and transverse processes, went perpend. got CSF rightaway. had great block (i used little more then usual dose of bupiv 0.75% for her height -1.8mL). for labor epidural, I had 2 pts with scoliosis that I've tried paramedian approach but on the convex side, worked well. if not, I was planning on waiting until she's 8-9cm dilated and in stage 2, then doing a spinal labor!

 

[florida]

If a harrington rod patient goes for GA c-section I would keep the difficult airway cart nearby. There was an airway nightmare a few months back- and her airway exam wasn't that bad. Those rods extended real high and neck extension wasn't good enough. Since then I just keep the possibility of a difficult intubation in the back of my head.

 

[florida]

If a harrington rod patient goes for GA c-section I would keep the difficult airway cart nearby. There was an airway nightmare a few months back- and her airway exam wasn't that bad. Those rods extended real high and neck extension wasn't good enough. Since then I just keep the possibility of a difficult intubation in the back of my head.

 

[epidural man]

Yes you can, and many older anesthesiologists used to do it regularly. It's very rare now.
Take a look at this:

http://www.asahq.org/Newsletters/1998/03_98/Epidural_0398.html

Cool article. Thanks!

Alternatively, if you can't do an epidural or spinal in a patient, and you don't have the cajones to attempt a caudal, try intradermal or subq sterile water injections on the back. There have been a few papers published on the success of this method to give some pretty good relief from labor pain (mostly low back labor pain).

here is a reference to one of the articles on this technique. Sorry I don't know how to use pubmed (I have always used ovid) and can't link it directly.

Martensson L. Wallin G. Labour pain treated with cutaneous injections of sterile water: a randomised controlled trial. British Journal of Obstetrics & Gynaecology. 106(7):633-7, 1999 Jul