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Tuesday, July 22, 2014
Spinal Anesthesia after Lumbar Fusion (L4-L5)
I am 35 years old and 30 weeks pregnant with my third child. I had a c-section in 2003 with my second child and ended up having to have a blood patch procedure for a postural headache after the spinal block. Since then, I had a discectomy/laminectomy at L4-L5 in June 2004 which also resulted in a postural headache due to complications from the surgery (a bone fragment tore a small hole in the dura). I had a dural repair 2 weeks after this surgery in June 2004. My disc then re-herniated and I ended up having an anterior fusion in Dec. 2007 and a posterior fusion in Jan. 2008 (with no complications and wonderful results). I became pregnant (not planned) in June 2008 and have another planned c-section for 11Mar09. I am wondering if it would be less risky to have general anesthesia for the c-section (considering my history of spinal leaks), or if it will be completely safe to have another spinal block? Also, do you recommend that I have a consult with anesthesia prior to the delivery?
Considering your history of post-dural puncture headache (PDPH)("spinal leaks") and of major spinal surgery I think many anesthesiologists would be reluctant to administer spinal anesthesia. PDPH occurs in roughly 1 in every 50 to 200 cases (0.5-2%). The incidence varies depending on the size of the needle used, and the number of needle insertions but sometimes happens even in the best hands. Spinal fusion reduces the mobility in your back and makes a spinal or epidural anesthetic technically more challenging. Your chances of having another PDPH are probably higher than average. If you do undergo spinal anesthesia and are unlucky enough to get another spinal headache, the recommended treatment, an epidural blood patch, may be rather difficult to perform.
General anesthesia, although usually a second choice for most mothers and babies, can be perfectly safe, provided you do not have any other problems, such as a difficult airway. We hate surprises, and, as you have already realized, the best course of action is to ask your obstetrician to help arrange a consult with a member of the anesthesia department in your hospital, way ahead of the delivery. There the risks and benefits of general anesthesia versus spinal anesthesia, for you, can be discussed, and the best plan agreed upon. Good luck!
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University