Central neuraxial blockade in an obstetric patient with subacute combined degeneration of the spinal cord

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House, K
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Introduction: Subacute combined degeneration of the spinal cord (SACD) is an acquired, reversable neurological condition with sensory, motor, psychological and haematological manifestations. Pathologically it is characterised by demyelination in the dorsal and lateral columns of the spinal cord which can be seen on MRI and is a result of vitamin B12 deficiency [1]. B12 is absorbed in the distal ileum with the aid of intrinsic factor and involved in the metabolic pathways responsible for maintaining myelin. The main causes are poor nutrition or absorption and drugs such as antacids and nitrous oxide. Case Report: A 28-year-old woman presented to the high-risk obstetric anaesthetic clinic in September 2022 with a history of SACD secondary to recreational nitrous oxide use. She was planning for a normal vaginal delivery. Her medical history was elicited. She had developed paraesthesia and weakness in her hands and feet in October 2021 which spread proximally and left her almost paralysed. She was found to have normal electromyography but low B12 levels, and a diagnosis of SACD was confirmed in December 2021. She was treated with vitamin B12 supplementation over several months and in June 2022 her B12 levels were in the normal range and MRI spine had no pathology evident. Her neurological symptoms improved over this time period to the point where, in clinic, she only had a remaining patch of numbness over her right thigh. After a review of the literature, which produced minimal evidence regarding safety of central neuraxial anaesthesia in this patient group (obstetric or otherwise), the risks and benefits of regional anaesthesia were discussed and agreed to be appropriate if required. The patient was admitted to the delivery suite several weeks later in spontaneous labour. She received a combined spinal epidural for labour, which was subsequently used for an emergency caesarean section. The patient was reviewed prior to discharge and appeared well with no deterioration in neurological function. She was then followed up over the next three months, in which time there was no development of neurological deficit. Discussion(s): There is no literature currently available that can guide decision making in this group of patients with regards to central neuraxial blockade. We hope that this case gives some evidence to its safety, although the question remains whether it would be appropriate in a patient that remained untreated and symptomatic at the time of delivery.
Research Subject Categories::MEDICINE::Surgery::Obstetrics and women's diseases
House K. (2023). Central neuraxial blockade in an obstetric patient with subacute combined degeneration of the spinal cord. International Journal of Obstetric Anesthesia, 54(Supplement 1), no pagination. https://doi.org/10.1016/j.ijoa.2023.103745