Neuraxial in patient with Harrington rods

[codeb1ue]

Just curious how everyone approaches this situation. I had a patient today for hip surgery who had rods down from L2-S1. She had a successful spinal in the past so I decided to just go for it right through her scar tissue. Thankfully I was successful. It got me wondering though what I would have done if this lady was pregnant on the LD floor and needed an epidural. I really don't think I would have been as lucky and instead put her at risk of a Dural puncture or even put her at risk of an infection of the hardware.



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[deleted162650]

Just curious how everyone approaches this situation. I had a patient today for hip surgery who had rods down from L2-S1. She had a successful spinal in the past so I decided to just go for it right through her scar tissue. Thankfully I was successful. It got me wondering though what I would have done if this lady was pregnant on the LD floor and needed an epidural. I really don't think I would have been as lucky and instead put her at risk of a Dural puncture or even put her at risk of an infection of the hardware.



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Not a lot of "Harrington rods" being placed any more - for quite a while actually so the chances of seeing them on L&D are becoming pretty rare. Unlike pedicle screws, the Harrington rods sit on the lateral aspect of the vertebrae, and if they were placed for scoliosis (most likely in the L&D crowd) then there is a good chance the epidural space is in tact and unmolested. That being said, the "safe" bet is to place the epidural above or below the levels of the rods if possible (like T12-L1 in the pt you describe). I would counsel that there might be an increased chance of a) difficult placement and b) PDPH and let the pt make her informed decision. Just be extra careful with your sterile technique, but I wouldn't let "fear of infection" prevent me from placing a labor epidural (that will be in place <24H) in a pt with hardware.

 

[Mman]

Just curious how everyone approaches this situation. I had a patient today for hip surgery who had rods down from L2-S1. She had a successful spinal in the past so I decided to just go for it right through her scar tissue. Thankfully I was successful. It got me wondering though what I would have done if this lady was pregnant on the LD floor and needed an epidural. I really don't think I would have been as lucky and instead put her at risk of a Dural puncture or even put her at risk of an infection of the hardware.



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spinals are easy even with hardware, epidurals might well be impossible depending on where the hardware is. I usually tell patients I can try to go above or below it for a labor epidural but they might have patchy spread that I can't fix and they are higher risk of a complication such as PDPH.

 

[Ezekiel2517]

I've placed labor epidurals in these patients. They are typically more difficult to place

 

[codeb1ue]

That is good to know people can have successful epidural even at the site of the rods itself .

Just to take this further, are there any back conditions or surgeries in which you would not even attempt a spinal or epidural? (Outside of the typical contraindications like bleeding and infection)

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[stonemd]

tethered cord?

 

[facted]

That is good to know people can have successful epidural even at the site of the rods itself .

Just to take this further, are there any back conditions or surgeries in which you would not even attempt a spinal or epidural? (Outside of the typical contraindications like bleeding and infection)

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Would be careful with Chiari patients as a csf leak could really worsen their neuro status. Also, Marfan patients are high risk for dural ectasia. Not a contraindication, but a spinal may not work properly due to uneven spread. Epidural would be recommended in this case.

 

[Shimmy8]

Last night had a spina bifida pt s/p some kind of repair (done elsewhere and we have no imaging in our system and patient didn't know) who also had a VP shunt.

GA for the repeat section.

 

[Phyzicz]

No interlaminar epidurals at levels of a laminectomy.

 

[pgg]

Would be careful with Chiari patients as a csf leak could really worsen their neuro status. Also, Marfan patients are high risk for dural ectasia. Not a contraindication, but a spinal may not work properly due to uneven spread. Epidural would be recommended in this case.

Huh, wouldn't have thought that someone with a connective tissue disorder would be better off with an epidural over a spinal. Would've bet on the opposite.

 

[Timeoutofmind]

No interlaminar epidurals at levels of a laminectomy.

Guaranteed spinal

 

[facted]

Huh, wouldn't have thought that someone with a connective tissue disorder would be better off with an epidural over a spinal. Would've bet on the opposite.

Dural ectasia doesn't affect epidural spread nearly as much as intrathecal spread. Failed spinals with dural ectasia are not uncommon. There's a few papers on pubmed I read about this a while back.

 

[codeb1ue]

No interlaminar epidurals at levels of a laminectomy.

So no epidural attempt at the same level of lami? What about microdiscectomies?

And how are fusions done now if not with rods?

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[Timeoutofmind]

So no epidural attempt at the same level of lami? What about microdiscectomies?

And how are fusions done now if not with rods?

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Yes, no epidural at level of lami, anywhere near a lami would be my recommendation. Without imaging, you really have little idea what level you are at. The scar on their back is not a reliable indicator of where you are working relative to the surgery as surgical approaches vary.

The issue is whether the ligamentum flavum is in tact. Otherwise, you will just plow right through to the dural sac. In any type of decompression surgery (such as a lami or a fusion) the flavum is removed, and basically so is the epidural space. Hence, I would not have done an epidural in the original pt you posted about.

As for your question with microdisc...depends

I do pain, so I would look at the MRI myself ahead of time, and I am not poking around blindly during the procedure so its apples and oranges...However, even if someone has had a microdisc and the flavum is in tact, I prob still would not do. There is scarring and alteration of anatomy resulting in increased risk of complications including bleeding. Think about "threading" a catheter through that scar tissue...a recipe for bleeding, dural tear, etc. A dozen plus case reports published of horrible complications with interlaminar (the approach you would be doing in OR/OB) epidural injections in the pain world in people who have had prior lumbar surgery at that level, and some at levels above/below.

Fairly conservative but would be my recommendation to generalist/OB type situations. Some might disagree. Would be curious to hear some other pain and OR guys chime in.

A spinal you can always do after lami/microdisc...you are just trying to spear a big sac with a small needle anyway.

As for your fusion question, some fusions are bony, so they dont have hardware...

More exotic surgeries and spine conditions would have their own considerations. Someone talked about Harrington Rods. I believe these are often placed without a decompression as they are simply to correct scoliosis, not to stabilize a spine that has been decompressed. I will ask my spine surgeon colleague though. So I would think an epidural would be reasonable for Harrington Rods/scoliosis pts.

And dont worry about hardware infection if your technique is totally sterile. Risk is very minimal.

And goes without saying that everything is R/B with the airway and what not if we are talking GA as the alternative.

Basically, I would just consult a CRNA, as with other advanced issues in Anesthesiology. They have equal training/experience, and are often more compassionate because they are nurses. I find them a good resource for these kinds of questions.

 

[nimbus]

Basically, I would just consult a CRNA, as with other advanced issues in Anesthesiology. They have equal training/experience, and are often more compassionate because they are nurses. I find them a good resource for these kinds of questions.

 

[deleted162650]

And how are fusions done now if not with rods?

Fusions are still done with rods, but not Harrington rods much any more. Harrington rods affixed to the lateral aspects of the vertebrae some how. Modern fusions are done with pedicle screws and rods that link the screws together across levels. These are not "Harrington rods." What is your background? Your profile says "fellow" yet you are asking med student level anesthesia questions.

 

[codeb1ue]

Fusions are still done with rods, but not Harrington rods much any more. Harrington rods affixed to the lateral aspects of the vertebrae some how. Modern fusions are done with pedicle screws and rods that link the screws together across levels. These are not "Harrington rods." What is your background? Your profile says "fellow" yet you are asking med student level anesthesia questions.

Ouch. Savage.

Believe it or not I am just starting out as a fresh attending. It's been a while since I've done or even thought about epidurals and I guess during residency I never paid attention to the details of the neurosurgery procedures other than which cases tend to bleed more and how to practice caution in prone cases.

This is also why I asked this question on this anonymous forum instead of my colleagues since I knew it was a very basic question. Still glad I asked though!

 

[Psai]

Ouch. Savage.

Believe it or not I am just starting out as a fresh attending. It's been a while since I've done or even thought about epidurals and I guess during residency I never paid attention to the details of the neurosurgery procedures other than which cases tend to bleed more and how to practice caution in prone cases.

This is also why I asked this question on this anonymous forum instead of my colleagues since I knew it was a very basic question. Still glad I asked though!

Well I learned from this thread thanks for posting

 

[Hoya11]

Yes, no epidural at level of lami, anywhere near a lami would be my recommendation. Without imaging, you really have little idea what level you are at. The scar on their back is not a reliable indicator of where you are working relative to the surgery as surgical approaches vary.

The issue is whether the ligamentum flavum is in tact. Otherwise, you will just plow right through to the dural sac. In any type of decompression surgery (such as a lami or a fusion) the flavum is removed, and basically so is the epidural space. Hence, I would not have done an epidural in the original pt you posted about.

As for your question with microdisc...depends

I do pain, so I would look at the MRI myself ahead of time, and I am not poking around blindly during the procedure so its apples and oranges...However, even if someone has had a microdisc and the flavum is in tact, I prob still would not do. There is scarring and alteration of anatomy resulting in increased risk of complications including bleeding. Think about "threading" a catheter through that scar tissue...a recipe for bleeding, dural tear, etc. A dozen plus case reports published of horrible complications with interlaminar (the approach you would be doing in OR/OB) epidural injections in the pain world in people who have had prior lumbar surgery at that level, and some at levels above/below.

Fairly conservative but would be my recommendation to generalist/OB type situations. Some might disagree. Would be curious to hear some other pain and OR guys chime in.

A spinal you can always do after lami/microdisc...you are just trying to spear a big sac with a small needle anyway.

As for your fusion question, some fusions are bony, so they dont have hardware...

More exotic surgeries and spine conditions would have their own considerations. Someone talked about Harrington Rods. I believe these are often placed without a decompression as they are simply to correct scoliosis, not to stabilize a spine that has been decompressed. I will ask my spine surgeon colleague though. So I would think an epidural would be reasonable for Harrington Rods/scoliosis pts.

And dont worry about hardware infection if your technique is totally sterile. Risk is very minimal.

And goes without saying that everything is R/B with the airway and what not if we are talking GA as the alternative.

Basically, I would just consult a CRNA, as with other advanced issues in Anesthesiology. They have equal training/experience, and are often more compassionate because they are nurses. I find them a good resource for these kinds of questions.

Agree. You go above or below the scar. At the scar is asking for a wet tap because the ligament has been removed. It is important to find out if it was a decompressive laminectomy or rods to correct scoliosis that spared the epidural space and midline. Maybe try looking up an old CXR or CT abdomen or chest to find out. Most pain guys have experience with spinal imaging and are able to tell if an epidural is possible based on imaging. Spinal always usually possible.

About microdisc, i treat it the same as any other scar. Go to a different level. The difference here being that the scar is smaller and more available levels.

Typically for a CS its not an issue, spinal away. For labor, options are either remi or some type of intrathecal analgesia with opiate and/or small doses of local. caudal? ive never tried this for labor pain but im curious about it

 

[deleted162650]

If a pt has a Hx of lumbar fusion, chances are they are better off with a C/S and not laboring anyways.

 

[Maverikk]

Any procedure that disrupts the epidural space...continuous spinal, 1/10 what you do for an epidural

 

[Arch Guillotti]

Any procedure that disrupts the epidural space...continuous spinal, 1/10 what you do for an epidural

What are you going to do when a blood patch is needed?

 

[Maverikk]

Same as doing a spinal drain for aortic procedure..give them time, fluids. if it's the day before discharge do the blood patch

 

[deleted162650]

Same as doing a spinal drain for aortic procedure..give them time, fluids. if it's the day before discharge do the blood patch

The point is: You did a continuous spinal because there was no epidural space there to begin with - so now how are you gonna patch them when there's no epidural space to patch??

 

[Psai]

The point is: You did a continuous spinal because there was no epidural space there to begin with - so now how are you gonna patch them when there's no epidural space to patch??

Just dump a unit in there

 

[Arch Guillotti]

The point is: You did a continuous spinal because there was no epidural space there to begin with - so now how are you gonna patch them when there's no epidural space to patch??

Simple. Wet tap them, pull the epidural needle back a couple of mm, then directly infuse a unit of blood through the Tuohy!

 

[codeb1ue]

What are you going to do when a blood patch is needed?

Correct me if I'm wrong but I recall learning the blood patch doesn't necessarily have to be at the same level as where you think the tear is since the blood, even at a completely different level, causes a diffuse inflammatory response of the dura that essentially seals up the tear anywhere along the spine.

 

[deleted162650]

I recall learning the blood patch doesn't necessarily have to be at the same level as where you think the tear is since the blood, even at a completely different level

This is correct.

causes a diffuse inflammatory response of the dura that essentially seals up the tear anywhere along the spine.

This is NOT correct.

The mechanism of action of an epidural blood patch is twofold. The first is mass effect of the blood in the epidural space which compresses the thecal sac thereby pushing axial CSF up into the cranial compartment, restoring CSF pressure and relieving the HA. The second is by local clot formation of the blood in the epidural space which seals the dural hole. Imaging studies have shown that blood injected in the lumbar region will make its way all the way up to the cervical epidural space which why you don't have to patch at the same level though I think most agree that you should try to be as close as possible.

I've never heard or read anything about an "inflammatory reaction."

If you give the pt a large dural hole in an area where there is no epidural space from prior surgery then no blood will make it to the region of the hole and it won't seal (although you may see some temporary relief from the mass effect).

 

[Ronin786]

What are you going to do when a blood patch is needed?

Sphenopalatine ganglion block.

 

[Scotty_G]

I was thinking more along the lines of stellate ganglion :0

 

[BLADEMDA]

I have performed dozens of epidurals for labor in patients with a history of back surgery or hardware. My technique is to go at least one level above any of the actual surgery. I prefer to be above the scar or at the top (cephelad) level of the scar itself. Typically, these epidurals work well for labor.

For spinals the important question to ask is what level the fusion is at. That's the key to a successful SAB in this patient population. Avoid the level where the lumbar spine is fused and go above or below those levels.

If it is a microdiskectomy then any level works just fine.

 

[Timeoutofmind]

I have performed dozens of epidurals for labor in patients with a history of back surgery or hardware. My technique is to go at least one level above any of the actual surgery. I prefer to be above the scar or at the top (cephelad) level of the scar itself. Typically, these epidurals work well for labor.

For spinals the important question to ask is what level the fusion is at. That's the key to a successful SAB in this patient population. Avoid the level where the lumbar spine is fused and go above or below those levels.

If it is a microdiskectomy then any level works just fine.

I respect you and enjoy a lot of your posts but your second two statements definitely are not correct (about spinals and microdiscs).

Please read my above post to get an idea why.

Just trying to help you out so you dont do something unwise in a clinical situation...no offense intended.

 

[BLADEMDA]

I respect you and enjoy a lot of your posts but your second two statements definitely are not correct (about spinals and microdiscs).

Please read my above post to get an idea why.

Just trying to help you out so you dont do something unwise in a clinical situation...no offense intended.

Thanks but I've been doing just fine for over 2 decades without you. As for a microdiskectomy whether you go through that particular level (where the surgery occurred) or choose another level it doesn't matter as the SAB is technically easy to perform. These days the scarring from a microdiskectomy is typically very minimal so the failure rate of the SAB (even at the level of the actual diskectomy) is very low.

If I decide to proceed with an SAB on patient with a lumbar fusion I generally avoid the level of the fusion itself and typically utilize the paramedian approach to be successful with a minimal number of attempts.

Spinal Anesthesia with Isobaric Tetracaine in Patients with Previous Lumbar Spinal Surgery

Does previous spinal surgery rule out epidurals? NetWellness

http://www.sld.cu/galerias/pdf/sitios/anestesiologia/regional_anesthesia_neurologic_patient.pdf

 

[BLADEMDA]

In recent years, spinal surgery techniques have improved with smaller incisions and less distortion of adjacent structures. The epidural space may be more accessible via the midline approach, and scar tissue may be reduced within the epidural space. Current microdiscectomy techniques may also create less scarring and distortion. Potentially, this could result in increased success of subsequent neuraxial techniques?

A most recent, large study seems to support this proposition. This prospective case-controlled study on labor analgesia demonstrated that parturients with a history of lumbar discectomy surgery can undergo neuraxial labor analgesia without an increased risk of difficult block initiation, epidural catheter failure, increased analgesic drug consumption, or longer time requirement for catheter placement.[26] No technical failures of the epidural or inadequate analgesia were noted, although 17% required greater than one interspace attempt compared to 2% in control group.[26]

Concerns have been expressed that the introduction of bacteria via epidural catheters may result in contamination of spinal instrumentation hardware and may lead to potentially devastating consequences. Fortunately, these concerns are not borne out by the literature.

Neuraxial blocks in parturients with scoliosis and after spinal surgery Sharma M, McConachie I - J Obstet Anaesth Crit Care

 

[deleted162650]

If I decide to proceed with an SAB on patient with a lumbar fusion I generally avoid the level of the fusion itself and typically utilize the paramedian approach to be successful with a minimal number of attempts.

Why? Fusions are generally accompanied by lami's which would make a midline approach even easier. The hardware and bony fusion are generally a bit lateral with the hardware over the pedicles and bone lateral to that.

 

[Pooh & Annie]

I respect you and enjoy a lot of your posts but your second two statements definitely are not correct (about spinals and microdiscs).

Please read my above post to get an idea why.

Just trying to help you out so you dont do something unwise in a clinical situation...no offense intended.

What am I missing? You yourself said you would do a SAB after a lami or microdisc because you're just putting a "spear in a big sac." I think most of us would agree with that. How is that different from what he said?

 

[Timeoutofmind]

What am I missing? You yourself said you would do a SAB after a lami or microdisc because you're just putting a "spear in a big sac." I think most of us would agree with that. How is that different from what he said?

As SaltyDog stated...makes no sense to avoid the level of fusion for SAB. The lamina, ligamentum flavum, and spinous processes (at times) are removed making this your easiest access. Going cephalad to it is unnecessary and increases the risk of cord injury given the fact that studies have shown we are poor at estimating the level we are working at by landmark type judgments.

And also a "paramedian approach" for SAB makes no sense at all. I am not sure if Blade is using paramedian in the sense of the classic technique of bouncing off the transverse process (used for blind thoracic epidurals), or if he just means "a little bit off the midline." In any case, both of those would be more difficult in a fusion pt with hardware in place, as you can see if you think about the below picture (typical hardware placement for fusion):

And to the new guys out there, I think that advice about going at the level of the microdisc is truly terrible given the concerns I listed in my first post (what is the advantage anyway?), but I guess its hard to teach an old dog new tricks!

 

[BLADEMDA]

Why? Fusions are generally accompanied by lami's which would make a midline approach even easier. The hardware and bony fusion are generally a bit lateral with the hardware over the pedicles and bone lateral to that.

I generally like to avoid the area of surgery If possible. A paramedian technique allows a skilled Anesthesiologist to Perform a SAB on almost any patient. Typically a lumbar fusion is L3 or lower leaving the L2 level readily available for an SAB.

Some degree of back pain post fusion is attributed to scarring and inflammation of the area and muscle spasm. I prefer to avoid doing anything that may promote muscle spasm in that area post fusion.

As for cord damage secondary to an SAB I haven't seen one in over 150,000 spinals at my facility (since I started there). So, the occurrence is very low when an experienced Anesthesiologist performs the procedure on the right patient population.

FYI, I have performed lumbar plexus blocks at the level of the hardware and while technically difficult to do the blocks worked well.

The bottom line is that for patients with a lumbar fusion an SAB can technically be performed without much more difficulty than your typical patient.

 

[Arch Guillotti]

FYI, I have performed lumbar plexus blocks at the level of the hardware and while technically difficult to do the blocks worked well.

No way I would ever do this.

 

[Arch Guillotti]

I have performed dozens of epidurals for labor in patients with a history of back surgery or hardware. My technique is to go at least one level above any of the actual surgery. I prefer to be above the scar or at the top (cephelad) level of the scar itself. Typically, these epidurals work well for labor.

My experience is that they tend to be crappy for labor and even worse for C/S.

 

[deleted162650]

I generally like to avoid the area of surgery If possible. A paramedian technique allows a skilled Anesthesiologist to Perform a SAB on almost any patient. Typically a lumbar fusion is L3 or lower leaving the L2 level readily available for an SAB.

Some degree of back pain post fusion is attributed to scarring and inflammation of the area and muscle spasm. I prefer to avoid doing anything that may promote muscle spasm in that area post fusion.

As for cord damage secondary to an SAB I haven't seen one in over 150,000 spinals at my facility (since I started there). So, the occurrence is very low when an experienced Anesthesiologist performs the procedure on the right patient population.

FYI, I have performed lumbar plexus blocks at the level of the hardware and while technically difficult to do the blocks worked well.

The bottom line is that for patients with a lumbar fusion an SAB can technically be performed without much more difficulty than your typical patient.

I agree with pretty much all of that. I don't do LPB's, but if I did, I probably wouldn't d them in the setting of hardware at the level.

 

[BLADEMDA]

I agree with pretty much all of that. I don't do LPB's, but if I did, I probably wouldn't d them in the setting of hardware at the level.

Yes, I would not encourage anyone to do a lumbar plexus block in the setting of a lumbar fusion with hardware; the block is technically very difficult to perform and these days the benefits of a LPB vs a 3 in 1 block or QL1/Q2 isn't worth the increased risks.

That said, I have done them in the past with good success.

 

[BLADEMDA]

My experience is that they tend to be crappy for labor and even worse for C/S.

My anecdotal experience and the published literature seem to support the notion that these Epidurals actually work pretty well for labor.

 

[BLADEMDA]

In a recent prospective study, 41 parturients with previous spinal instrumentation for scoliosis correction were matched with controls, epidural bupivacaine consumption and time to placement of neuraxial technique were compared.[23] Total bupivacaine consumption, number of manual boluses, and number of subjects requiring increased bupivacaine concentrations did not differ between the groups. However, in the scoliosis group, mean time to complete the neuraxial technique was 41% longer, the number of needle redirections and attempted interspaces required were more, and the need for a more experienced provider was more. Successful analgesia was achieved in 88% women in the scoliosis group.

Further studies are required to estimate the rate of successful and reliable conversion from epidural labor analgesia to surgical anesthesia for cesarean delivery given the high requirement of extensive dermatomal spread and denser anesthesia for an operative delivery. The conversion failure rate may be greater in women with spine instrumentation compared with analgesia, but this possibility remains unproven.

It is also worth noting that epidural blood patch is usually not possible should the patient develop a postdural puncture headache. Although the case reports are sparse, yet a case of postdural puncture headache in a nonparturient, who developed headache following spinal surgery and instrumentation, was successfully treated by computed tomography (CT)-guided translaminar epidural blood patch.[24]

Neuraxial blocks in parturients with scoliosis and after spinal surgery Sharma M, McConachie I - J Obstet Anaesth Crit Care

 

[deleted162650]

In a recent prospective study, 41 parturients with previous spinal instrumentation for scoliosis correction were matched with controls, epidural bupivacaine consumption and time to placement of neuraxial technique were compared.[23] Total bupivacaine consumption, number of manual boluses, and number of subjects requiring increased bupivacaine concentrations did not differ between the groups. However, in the scoliosis group, mean time to complete the neuraxial technique was 41% longer, the number of needle redirections and attempted interspaces required were more, and the need for a more experienced provider was more. Successful analgesia was achieved in 88% women in the scoliosis group.

Further studies are required to estimate the rate of successful and reliable conversion from epidural labor analgesia to surgical anesthesia for cesarean delivery given the high requirement of extensive dermatomal spread and denser anesthesia for an operative delivery. The conversion failure rate may be greater in women with spine instrumentation compared with analgesia, but this possibility remains unproven.

It is also worth noting that epidural blood patch is usually not possible should the patient develop a postdural puncture headache. Although the case reports are sparse, yet a case of postdural puncture headache in a nonparturient, who developed headache following spinal surgery and instrumentation, was successfully treated by computed tomography (CT)-guided translaminar epidural blood patch.[24]

Neuraxial blocks in parturients with scoliosis and after spinal surgery Sharma M, McConachie I - J Obstet Anaesth Crit Care

I thought we already established that scoliosis correction is more likely to leave an intact flavum and epidural space and therefore pose less challenge and risk for epidurals. I don't think you can extrapolate this study to its who have had lami/fusion surgery.

 

[Timeoutofmind]

I thought we already established that scoliosis correction is more likely to leave an intact flavum and epidural space and therefore pose less challenge and risk for epidurals. I don't think you can extrapolate this study to its who have had lami/fusion surgery.

Agreed.

Blade, you seem to have a knowledge gap with anatomy of the spine and associated surgical and neuraxial procedures.

Also, it does not seem like you are actually comprehending the posts in this thread in terms of the anatomy being discussed.

I am not going to go back and forth with you for this reason, unless you are looking for clarification or something. Your anecdotal experiences from your hospital system and these random articles are not really helpful. My last few posts were more for the benefit of the rest of the forum.

I would recommend sitting down with an atlas and google and looking up terms and procedures you are not familiar with.

Unless someone else has some sort of relevant question, I'm peace'd out of this thread!

 

[BLADEMDA]

I thought we already established that scoliosis correction is more likely to leave an intact flavum and epidural space and therefore pose less challenge and risk for epidurals. I don't think you can extrapolate this study to its who have had lami/fusion surgery.

Sure, I'll admit there is a higher chance that the lower Lumbar and Sacral dermatomes may not be covered well with an Epidural s/p lumbar fusion. Fortunately, the number of laboring females s/p lumbar fusion is pretty rare so even my N number is rather small. My larger anecdotal experience is s/p surgery for scoliosis but even that number is less than 15.

I certainly wouldn't want to rely on an Epidural for surgical level anesthesia and would be very concerned if these patients were about to undergo a C section with that epidural as the primary anesthetic.

But, the bottom line is I would still attempt a labor epidural for analgesia in these patients (at the level above the surgery if possible) if there are no other contraindications.

 

[BLADEMDA]

Spinal Anesthesia with Isobaric Tetracaine in Patients with Previous Lumbar Spinal Surgery

Clearly the above article is anything but a "random article" for this thread.

For those of us in private practice another "key point" is that this subgroup of patients is far more likely to complain of back pain after the surgical procedure than those patients without a history of back problems:

"We found that 7 of 14 patients (50%) with pre-existing back pain complained of worsening of the persistent back pain and 2 patients in PLSS group complained of newly developed back pain. Also, 4 of 10 patients (40%) with pre-existing back pain in Control group complained of worsening of the persistent back pain."

 

[BLADEMDA]

"Our series is the first to characterize the frequency and severity of neurologic events after neuraxial blockade in patients with previously diagnosed spinal stenosis or lumbar disk disease (with or without prior spinal decompressive surgery). Our major findings suggest that this patient population is at increased risk for worsening of preexisting or the development of new neurologic deficits postoperatively when compared with the general population,6,18 and that the presence of multiple neurologic diagnoses (radiculopathy, spinal stenosis, peripheral neuropathy) increases the risk."

Neuraxial Blockade in Patients with Preexisting Spinal Steno... : Anesthesia & Analgesia

The article was interesting but the authors did Neuraxial blocks in patients that I would not offer that option to in my practice.

 

[BLADEMDA]

Our results also demonstrated that a history of spinal surgery did not increase the risk of technical or neurologic complications or affect block success. Previous spinal surgery has often been considered a relative contraindication to the use of neuraxial blockade. Many of these patients experience chronic back pain and are reluctant to undergo epidural or spinal anesthesia, fearing exacerbation of their preexisting back complaints. Several postoperative anatomic changes make needle or catheter placement more difficult and complicated after major spinal surgery. The presence of adhesions or obliteration of the epidural space from scar tissue may increase the incidence of dural puncture or decrease the spread of local anesthetic within the epidural space, producing an incomplete or failed block. Needle placement in an area of the spine that has undergone bone grafting and posterior fusion may not be possible with midline or lateral approaches; needle insertion can be accomplished only at unfused segments.

Neuraxial Blockade in Patients with Preexisting Spinal Steno... : Anesthesia & Analgesia