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Childbirth related neurological injury

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Lecture from 2020 #OBAnes Belgium symposium

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Childbirth related neurological injury

  1. 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
  2. 2. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes INCIDENCE
  3. 3. 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
  4. 4. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  5. 5. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  6. 6. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes D’Angelo et al. Anesthesiology 2014:120;1505-12
  7. 7. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes D’Angelo et al. Anesthesiology 2014:120;1505-12
  8. 8. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Davies et al. Clin Obstet Gynecol 2017:60;431-446 Davies et al. Anesthesiology 2009:110;131-139
  9. 9. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes • Traumatic • CSF leal • Nerve injury • Infective • Epidural Abscess • Meningitis • Ischemic • Spinal Cord Injury • Chemical • Arachnoiditis
  10. 10. 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
  11. 11. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Neuraxial Hematoma Kreppel D, et al. Neurosurg Rev 2003;26:1–49
  12. 12. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Guffey et al. A&A 2010:111:992
  13. 13. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Guffey et al. A&A 2010:111:992
  14. 14. 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
  15. 15. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  16. 16. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  17. 17. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Magnetic Resonance Imaging Davidson et al. A&A 2010;110:233-237
  18. 18. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound*
  19. 19. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound* Saifuddin A. Spine 1998:23:1452-6
  20. 20. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Direct Trauma • Paraesthesia • +/- Injection • Conus Medullaris Syndrome • Numbness > Pain & Paraesthesia • Interspace misidentification • Ultrasound* Broadbent CR. Anaesthesia 2000:55:1122-1126
  21. 21. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Ischemia
  22. 22. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  23. 23. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  24. 24. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  25. 25. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes “Tiger country”
  26. 26. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Intrinsic Obstetric Palsies
  27. 27. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Lumbrosacral Plexus
  28. 28. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Lumbrosacral Trunk Lumbrosacral Trunk
  29. 29. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Lumbrosacral Trunk Lumbrosacral Trunk
  30. 30. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Obturator Nerve Palsy
  31. 31. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Femoral Nerve Palsy
  32. 32. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Femoral Nerve Palsy
  33. 33. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Meralgia Paresthetica
  34. 34. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Sciatic Nerve Palsy
  35. 35. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Peroneal Nerve Palsy
  36. 36. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Peroneal Nerve Palsy
  37. 37. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Evaluation
  38. 38. 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
  39. 39. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Foot Drop - DDx Tsen L. Int Anesth Clinics 2002:40;67-88
  40. 40. 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
  41. 41. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes
  42. 42. UniversityofCaliforniaSanFrancisco@Ron_George #BelgiumOBAnes Evaluation • History and Physical Exam • Consultation - Neurology / Neurosurgery • Magnetic Resonance Imaging (MRI) • Electromyography (EMG)
  43. 43. Questions Ronald.George@ucsf.edu @Ron_George

Lecture from 2020 #OBAnes Belgium symposium

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