Chronic Spinal Cord Injury

Question 1

A 32 year-old female patient is listed for an elective Caesarean section. She has a history of mild asthma, for which she takes salbutamol, and had a spinal cord injury following a road traffic accident 5 years ago. You are asked to review her prior to her procedure.
How would you assess this patient?

1) History

Answer 1

• Take a detailed history of the symptoms, complications and treatment following the spinal cord injury. Knowledge of the level of the spinal cord injury will be essential to form an appropriate management plan. The history should include:
• Any previous episodes of autonomic dysreflexia.
• The presence of symptoms suggestive of central sleep apnoea.
• Any prolonged ventilation or tracheostomy.
• Current pressure sores.
• Current treatment of chronic pain and/or spasticity.
• Take a medical history including the severity of asthma and any past hospital admissions.
• Ask the patient about previous anaesthetics, in particular those following the road traffic accident and review the anaesthetic charts if they are available.

Question 2

How would you assess this patient?

Examination & Investigations?

Answer 2

Examination:
* Conduct cardiovascular, respiratory and neurological examinations including palpation of the spinous processes to determine the ease of neuraxial blockade if necessary.
* Carry out an airway assessment. The patient may present with a potential difficult airway depending on the level of the spinal cord injury and/or spinal fixation that may have occurred.

Investigations:
* Bedside observations including blood pressure and heart rate at rest.
* Baseline blood tests to include clotting and a cross-match if indicated.
* Further investigations should be guided by the patient’s
comorbidities and symptoms, but may include an ECG, echo and lung function tests.

Question 3

What are the key concerns in patients presenting with a chronic spinal cord injury?

Airway, respiratory?

Answer 3

• The level of the spinal cord lesion will determine its effect on ventilation. Lesions above C5 will require ventilatory support.
• Decreased lung volumes and poor muscle function secondary to the neurological injury may predispose the patient to atypical respiratory tract infections and aspiration.
• Surgical fixation of the cervical spine may cause difficulty with intubation and ventilation.

Question 4

What are the key concerns in patients presenting with a chronic spinal cord injury?

CVS?

Answer 4

• Autonomic dysreflexia may occur during peri-operative period, causing massive haemodynamic instability and end-organ damage e.g. myocardial infarction.
• There is an increased risk of undiagnosed ischaemic heart disease in this patient due to reduced movement and exercise levels.
• The patient presents with a high risk of VTE secondary to immobility.
• The patient will have an overall reduction in plasma volume and haemoglobin concentration, which may be significant if there is significant blood loss peri-operatively.

Question 5

Key concerns

Neurological, other?

Answer 5

Neurological system:
* Spasticity and contractures can make patient positioning and the surgical procedure challenging, and may require extra time.
* Previous spinal surgery can lead to unreliable neuraxial blockade.
* Patients with chronic spinal cord injuries have a high incidence of
chronic pain.

Other
* Impaired haemostasis and temperature control.
* Delayed gastric emptying.
* Chronic urinary retention and a high incidence of urinary tract infections.

Question 6

What are the options for anaesthesia in this patient?

Answer 6

The anaesthetic technique should be chosen based on the level of the lesion, the procedure (in this case, a Caesarean section) and the symptoms and preference of the patient. It should be decided following a MDT discussion involving the patient, obstetrician, anaesthetist and neurosurgical team. The options for anaesthesia are detailed below.
* GA
* Neuraxial blockade (it would be prudent to discuss this with the
neurosurgical team prior to the procedure).
* No anaesthetic (if the patient does not have autonomic dysrefexia and
has no sensation in the neurological distribution of the surgical site).

Question 7

The Caesarean section is carried out under a spinal anaesthetic. During the procedure, the patient suddenly complains of a headache and blurred vision, with difficulty in breathing. On examination her chest is fushed and her blood pressure is 178/93.
How do you manage this?

Answer 7

• Call for help, alert the theatre team and conduct a rapid ABCDE assessment of patient.
• This is possible autonomic dysrefexia, which is a medical emergency and should be treated immediately.
• Pause the surgery as soon as possible.
• Position the patient in a reverse Trendelenburg position.
• Check the level of neuraxial blockade and consider a general anaesthetic if inadequate.
• Administer a short-acting antihypertensive agent e.g. sublingual nifedipine.
• Check the urinary catheter to ensure adequate drainage.
• Consider other causes in the differential diagnosis e.g. pain, pre-eclampsia.
• Consider level 2/3 care postoperatively if haemodynamic instability continues and discuss with a specialist.