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Combined Spinal-Epidural Analgesia for Laboring Parturient with Arnold-Chiari Type I Malformation: A Case Report and a Review of the Literature

DOI: 10.1155/2013/512915

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Abstract:

Anesthetic management of laboring parturients with Arnold-Chiari type I malformation poses a difficult challenge for the anesthesiologist. The increase in intracranial pressure during uterine contractions, coughing, valsalva maneuvers, and expulsion of the fetus can be detrimental to the mother during the process of labor and delivery. No concrete evidence has implicated high cerebral spinal fluid pressure on maternal and fetal complications. The literature on the use of neuraxial techniques for managing parturients with Arnold-Chiari is extremely scarce. While most anesthesiologists advocate epidural analgesia for management of labor pain and spinal anesthesia for cesarean section, we are the first to report the use of combined spinal-epidural analgesia for managing labor pain in a pregnant woman with Arnold-Chiari type I malformation. Also, we have reviewed the literature and presented information from case reports and case series to support the safe usage of neuraxial techniques in these patients. 1. Introduction Arnold-Chiari type I malformation (ACM-I) is a congenital neurological anomaly associated with prolapse of the cerebellar tonsils into the magnum foramen [1, 2]. Approximately 30% to 50% of the ACM-I patients have associated syringomyelia. Incidence of ACM-I ranges between 0.56% and 0.77% on magnetic resonance imaging (MRI) studies, of which 15% to 30% are asymptomatic. This abnormality is mostly predisposed to women, with a female-to-male ratio of 3?:?1. Symptoms including headaches, neck and shoulder pain, paresthesia, loss of pain and temperature sensation in the upper extremities, and unsteady gait are the usual manifestations seen during early adolescence into adulthood. Severity of the symptoms ranges from mild when tonsillar herniation is larger than 5?mm to severe if it is more than 12?mm on the sagittal MRI view [3]. A combined spinal-epidural (CSE) technique was used to provide labor analgesia for our parturient with ACM-I. We also conducted a literature search for our case presentation using a public accessible medical database MEDLINE. Individual key words were entered into the query: “Arnold-Chiari,” “vaginal delivery,” “pregnancy,” “combined spinal-epidural analgesia,” “epidural analgesia,” “spinal analgesia,” “cesarean section,” “perioperative outcomes,” and their combinations. Only articles in English language were selected. The database search yielded limited number of articles, mainly case reports and case series (Table 1). Table 1: Summary of anesthetic management of patients with Arnold-Chiari type I malformation. 2. Case

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