Childbirth related neurological injury
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Lecture from 2020 #OBAnes Belgium symposium
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Childbirth related neurological injury
- 1. UniversityofCaliforniaSanFrancisco @Ron_George @RonaldBGeorge Neurologic complications associated with neuraxial anesthesia & pregnancy Ronald B. George, MD FRCPC Professor, Anesthesia & Perioperative Care Chief, Obstetric Anesthesia Betty Irene Moore Women’s Hospital at Mission Bay University of California San Francisco
- 4. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Seizures Peripheral Neuropathy Cauda Equina Syndrome Meningitis Spinal (5,640) 0 n = 2 (0.0–12.4) 0 0 Epidural (29,732) n = 2 (0.0–2.4) 0 0 0 Epidural 200,000 Spinal 50,000
- 7. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes D’Angelo et al. Anesthesiology 2014:120;1505-12
- 8. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes D’Angelo et al. Anesthesiology 2014:120;1505-12
- 9. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Davies et al. Clin Obstet Gynecol 2017:60;431-446 Davies et al. Anesthesiology 2009:110;131-139
- 10. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes • Traumatic • CSF leal • Nerve injury • Infective • Epidural Abscess • Meningitis • Ischemic • Spinal Cord Injury • Chemical • Arachnoiditis
- 11. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Neuraxial Hematoma • Acute back / radicular pain • Weakness / bowel & bladder • Prompt neurosurgical consultation and MRI imaging • Decompression within 6-8 hours Wong CA. BPR Clin Obstet Gyne 2010:24:367
- 12. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Neuraxial Hematoma Kreppel D, et al. Neurosurg Rev 2003;26:1–49
- 13. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Guffey et al. A&A 2010:111:992
- 14. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Guffey et al. A&A 2010:111:992
- 15. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Epidural Abscess • Symptoms 4-10 days following neuraxial procedure • Severe back pain +/- radicular pain • Fever, neck stiffness • Prompt neurosurgical consultation and MRI imaging • Staphylococcus aureus Royakers et al. Acta Anaesth Stand 2002;46:611-5
- 19. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Magnetic Resonance Imaging Davidson et al. A&A 2010;110:233-237
- 20. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound*
- 21. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound* Saifuddin A. Spine 1998:23:1452-6
- 22. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound* Broadbent CR. Anaesthesia 2000:55:1122-1126
- 30. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Lumbrosacral Trunk Lumbrosacral Trunk
- 31. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Lumbrosacral Trunk Lumbrosacral Trunk
- 40. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Evaluation • Motor function • 5/5 = full power • 4/5 = movement against resistance • 3/5 = movement against gravity • 2/5 = movement with gravity eliminated • 1/5 = trace movement • 0/5 = no visible movement • Reflexes • 4/4 = hyperreflexia with clonus • 3/4 = hyperreflexia • 2/4 = normal when symmetric • 1/4 = diminished but normal when symmetric • 0/4 = absent • Sensory • L1 = Inguinal crease • L2 = Anterior thigh • L3 = Medial knee • L4 =Medial malleolus • L5 = Dorsum web great toe • S1 = Lateral heel Brief & Comprehensive
- 41. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Foot Drop - DDx Tsen L. Int Anesth Clinics 2002:40;67-88
- 42. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Roots Sensory Motor Lateral Femoral Cutaneous L2 - L3 Anterolateral Thigh N/A Femoral L2 - L4 Anteromedial Thigh Medial Calf Hip Flexion Knee Extension Obturator L2 - L4 Medial Thigh Medial Knee Hip Adduction Lumbrosacral Plexus L1 - S4 Lateral Leg Dorsum Foot Ankle Dorsiflexion Hip Extension Sciatic L4 - S3 Posterior Thigh Lateral Leg Knee Flexion Peroneal L4 - S2 Anteriolateral Leg Dorsum Foot & toes Ankle Dorsiflexion & Eversion Posterior Tibial L4 - S3 Sole of Foot Ankle Plantarflexion & Inversion
- 44. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Evaluation • History and Physical Exam • Consultation - Neurology / Neurosurgery • Magnetic Resonance Imaging (MRI) • Electromyography (EMG)