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Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia.

Ghaly RF, Candido KD, Sauer R, Knezevic NN - Surg Neurol Int (2012)

Bottom Line: We used a multimodal general anesthesia without neuromuscular blockade.The neck was maintained in a neutral position.Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.

ABSTRACT

Background: Type I Arnold-Chiari malformation (ACM) has an adult onset and consists of a downward displacement of the cerebellar tonsils and the medulla through the foramen magnum. There is paucity of literature on the anesthetic management during pregnancy of residual ACM Type I, with cervical xyphosis and persistent syringomyelia.

Case description: A 34-year-old woman with surgically corrected ACM Type I presented for Cesarean delivery. A recent MRI demonstrated worsening of cervical xyphosis after several laminectomies and residual syringomyelia besides syringopleural shunt. Awake fiberoptic intubation was performed under generous topical anesthesia to minimize head and neck movement during endotracheal intubation. We used a multimodal general anesthesia without neuromuscular blockade. The neck was maintained in a neutral position. Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

Conclusions: The present case demonstrates that patients with partially corrected ACM, syringomyelia, cervical kyphosis, and difficult intubation undergoing Cesarean delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

No MeSH data available.


Related in: MedlinePlus

Sagittal T2 MRI image demonstrates severe post-laminectomy (C1–C6) cervical kyphosis (C2–C5), syringomyelia, and partially corrected Arnold–Chiari malformation Type 1 (tonsils below foramen magnum). Please notice crowding of the posterior fossa and anterior position of the larynx
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Figure 1: Sagittal T2 MRI image demonstrates severe post-laminectomy (C1–C6) cervical kyphosis (C2–C5), syringomyelia, and partially corrected Arnold–Chiari malformation Type 1 (tonsils below foramen magnum). Please notice crowding of the posterior fossa and anterior position of the larynx

Mentions: A 34-year-old, gravida 2 para 1 parturient was scheduled for Cesarean section at 38 weeks of gestational age. At age 19, she presented with paresthesias, headaches, neck pain, and poor balance, and Type I ACM with an extensive syringomyelia from the cervical to the lumbar area. Over the next several years, she had undergone surgical treatments, including suboccipital craniectomy, duraplasty with fascia lata graft, and decompressive C1–C6 laminectomies with placement of a syringopleural shunt. As a consequence of the laminectomies, the patient had residual cervical xyphosis with limited extension and continued to have symptoms related to Type I ACM, such as headaches, neck pain, stiffness, poor balance, and bilateral paresthesias of the upper and lower extremities (left side worse than right). Her symptoms were worsened by straining, coughing, and neck movements. Due to her residual Type I ACM, her neurosurgeon recommended avoiding normal vaginal delivery. The preoperative anesthetic evaluation showed a Mallampati grade III airway, limited mouth opening to 4 cm, and limited neck movement, with an anticipated difficult airway intubation. Recent MRI imaging of the cervical spine demonstrated worsening of the post-laminectomy cervical kyphosis, spinal cord atrophy, and a residual syrinx. The spinal cord was deviated posteriorly, the MRI of the thoracic spine demonstrated a syrinx in the entire thoracic cord, and the MRI of the brain showed structures of the hindbrain protruding through the foramen magnum [Figures 1–3].


Anesthetic management during Cesarean section in a woman with residual Arnold-Chiari malformation Type I, cervical kyphosis, and syringomyelia.

Ghaly RF, Candido KD, Sauer R, Knezevic NN - Surg Neurol Int (2012)

Sagittal T2 MRI image demonstrates severe post-laminectomy (C1–C6) cervical kyphosis (C2–C5), syringomyelia, and partially corrected Arnold–Chiari malformation Type 1 (tonsils below foramen magnum). Please notice crowding of the posterior fossa and anterior position of the larynx
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3307238&req=5

Figure 1: Sagittal T2 MRI image demonstrates severe post-laminectomy (C1–C6) cervical kyphosis (C2–C5), syringomyelia, and partially corrected Arnold–Chiari malformation Type 1 (tonsils below foramen magnum). Please notice crowding of the posterior fossa and anterior position of the larynx
Mentions: A 34-year-old, gravida 2 para 1 parturient was scheduled for Cesarean section at 38 weeks of gestational age. At age 19, she presented with paresthesias, headaches, neck pain, and poor balance, and Type I ACM with an extensive syringomyelia from the cervical to the lumbar area. Over the next several years, she had undergone surgical treatments, including suboccipital craniectomy, duraplasty with fascia lata graft, and decompressive C1–C6 laminectomies with placement of a syringopleural shunt. As a consequence of the laminectomies, the patient had residual cervical xyphosis with limited extension and continued to have symptoms related to Type I ACM, such as headaches, neck pain, stiffness, poor balance, and bilateral paresthesias of the upper and lower extremities (left side worse than right). Her symptoms were worsened by straining, coughing, and neck movements. Due to her residual Type I ACM, her neurosurgeon recommended avoiding normal vaginal delivery. The preoperative anesthetic evaluation showed a Mallampati grade III airway, limited mouth opening to 4 cm, and limited neck movement, with an anticipated difficult airway intubation. Recent MRI imaging of the cervical spine demonstrated worsening of the post-laminectomy cervical kyphosis, spinal cord atrophy, and a residual syrinx. The spinal cord was deviated posteriorly, the MRI of the thoracic spine demonstrated a syrinx in the entire thoracic cord, and the MRI of the brain showed structures of the hindbrain protruding through the foramen magnum [Figures 1–3].

Bottom Line: We used a multimodal general anesthesia without neuromuscular blockade.The neck was maintained in a neutral position.Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.

ABSTRACT

Background: Type I Arnold-Chiari malformation (ACM) has an adult onset and consists of a downward displacement of the cerebellar tonsils and the medulla through the foramen magnum. There is paucity of literature on the anesthetic management during pregnancy of residual ACM Type I, with cervical xyphosis and persistent syringomyelia.

Case description: A 34-year-old woman with surgically corrected ACM Type I presented for Cesarean delivery. A recent MRI demonstrated worsening of cervical xyphosis after several laminectomies and residual syringomyelia besides syringopleural shunt. Awake fiberoptic intubation was performed under generous topical anesthesia to minimize head and neck movement during endotracheal intubation. We used a multimodal general anesthesia without neuromuscular blockade. The neck was maintained in a neutral position. Following delivery, the patient completely recovered in post-anesthesia care unit (PACU), with no headache and no exacerbation or worsening of neurological function.

Conclusions: The present case demonstrates that patients with partially corrected ACM, syringomyelia, cervical kyphosis, and difficult intubation undergoing Cesarean delivery require an interdisciplinary team approach, diligent preparation, and skilled physicians.

No MeSH data available.


Related in: MedlinePlus