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Stéphane Moffett MD,FRCPC University of Ottawa. Postpartum Neurological Complications. Plan. CHESTNUT ch. 33 Cases Mechanisms of Nerve Injury Complications of Neuraxial Technique Trauma, TNS, hematoma, infections and others… Peripartum Back Pain Obstetric Nerve Palsies

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St phane moffett md frcpc university of ottawa

Stéphane Moffett MD,FRCPC

University of Ottawa

Postpartum Neurological Complications


Postpartum neurological complications

Plan

  • CHESTNUT ch. 33

  • Cases

  • Mechanisms of Nerve Injury

  • Complications of Neuraxial Technique

    • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric Nerve Palsies

  • Evaluation of PP Neuro Complaint


  • Case 1

    Case 1

    • 26yo primip, normal pregnancy

    • Easy insertion of epidural in early labor, no issues… worked well

    • Stage 2 lasted 2 hours, pushed 1 hour, spontaneous delivery

    • Postpartum day (PPD) 1 c/o isolated unilateral numb patch lateral thigh

    • No discernible motor or reflex deficit


    Case 2

    Case 2

    • 28yo primip, normal pregnancy

    • Epidural 6-7 cm deep, multiple attempts by staff, relieved, easy insertion by PGY2

    • PPD 1 c/o difficulty with hip flexion, walking

    • Weak hip flexors, quads, diminished patellar reflex, numb anterior thigh


    Case 3

    Case 3

    • 24yo multip, normal pregnancy, low back pain, bilateral leg pain

    • Uneventful labor, epidural placed mid stage 1, easy insertion, worked well

    • PPD 1, difficulty walking

    • Pain infra-umbilical, radiating into both legs, buttocks

    • Awkward antalgic, waddling gait

    • No motor, sensory or reflex deficit


    Case 4

    Case 4

    • 32yo 6 mo PP, primip, normal pregnancy

    • History of R sciatica 5y ago, resolved

    • Easy insertion L3-4 epidural mid stage1, worked well, no issues

    • 6lbs OP baby, 4 hours 2nd stage

    • Numbness anterolateral thigh, medial at knee

    • Absent knee jerk, unable to detect full bladder

    • Poor in hospital note by GP, anesthesia resident consult (no evidence of staff involvement)

    • DC’d home no investigations or follow-ups


    Case 4 cont d

    Case 4 (cont’d)

    • Now…

      • Sensation returned to normal

      • Physio for weakness, difficulty climbing up stairs

      • Left leg diffuse weakness

      • No sensory or reflex deficit


    Postpartum neurological complications

    Plan

    • Cases

    • Mechanisms of Nerve Injury

    • Complications of Neuraxial Technique

      • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric nerve Palsies

  • Evalluation of PP Neuro Complaint


  • Peripheral nerve anatomy grant neurosurgery 1999 44 825

    Peripheral Nerve AnatomyGrant, Neurosurgery 1999; 44: 825

    • Differences with CNS

      • Recovery through

        remyelination and axonal

        regeneration

  • 3 components:

    • Conducting axons

    • Insulating Schwann cells

    • Surrounding connective

      tissue matrix

  • Basal laminae

    • envelops Schwann cells

    • Supports axonal regeneration after injury

    • (serves as highway for growing nerve fibers)


  • Grading pn injury

    Grading PN Injury

    • Determined by magnitude/duration of injury

    • Seddon defined 3 grades based

      on extent of injury to the 3 structural

      components

    • Neuropraxia

      • Disrupts myelin but intact axon

  • Axonotmesis

    • Disrupts myelin and axon but laminae intact

  • Neurotmesis

    • Disrupts all 3 components


  • Neuropraxia

    Neuropraxia

    • Mildest nerve injury

    • Reduction or complete blockage of conduction across a segment of a nerve

    • Axonal continuity preserved,

    • Conduction preserved proximal and distal to lesion, not across

    • Compression, traction, ischemic, metabolic, toxic

    • Remyelination will restore normal conduction

    • Recovery within days to weeks


    Axonotmesis

    Axonotmesis

    • Axonal interruption with surrounding connective tissue(CT) preservation, able to support axonal regeneration

    • Distal Wallerian degeneration over several days

    • Failed conduction at and distal to injury site

    • Axonal regeneration across CT, Schwann cells proliferating and forming longitudinal conduit

    • Recovery over months

    • 1mm/day or 1inch/month

    • The more proximal the injury, the longer the recovery


    Neurotmesis

    Neurotmesis

    • Most severe grade

    • Recovery through regeneration cannot occur

    • Intraneural fibrosis blocks axonal regeneration

    • Continuity interrupted

    • If nerve transection, surgery required to reapproximate sheath

    • Recovery prolonged and incomplete


    Postpartum neurological complications

    Plan

    • Cases

    • Mechanisms of Nerve Injury

    • Complications of Neuraxial Technique

      • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric Nnerve Palsies

  • Evaluation of PP Neuro Complaint


  • Maternal neurologic injuries

    Maternal Neurologic Injuries

    • Uncommon 1:2000-1:6000 (1935-1965)

    • Causes

      • Spontaneous

      • Intrinsic to L+D process

      • Result directly/indirectly from

        • Obstetric interventions

        • Anesthesia interventions

    • ASA closed claim database (Chadwick, IJOA 1996; 5: 258)

      • Depending on timing of entry

      • Obs claims to nerve damage :

        • 10-16%

        • 3rd most common injury claim


    Maternal neurologic injury

    Maternal Neurologic Injury

    • Temporal association to neuraxial technique

    • Anesthesiologists 1st notified

    • Neuraxial block usually incriminated until proven otherwise

    • …although they are much more likely to have an obstetrical cause


    Epidural

    Epidural

    • Incidence 0-36.2: 10,000 blocks

    • Similar to general population 2-12: 10,000 blocks

    • Scott and Hibbard BJA 1990, 64, 537

      • Among the complications

        • Neuropathy 80.9%

        • Cranial nerve palsy 10.6%

        • Epidural abscess 2.1%

        • Epidural hematoma 2.1%

        • Anterior spinal artery syndrome 2.1%

        • Cranial subdural hematoma 2.1%


    Spinal

    Spinal

    • Incidence 3.5-35.4: 10,000 blocks

    • General population 0.3-70.3: 10,000 blocks

    • SAB/epid, majority had pain/paresthesia during it


    Cnb complications sweden

    CNB Complications- Sweden

    • 1990-9 (Moen Anesthesiology 2004;10:950)

      • Approximately 1,260,000SAB, 450,000EB of which 200,000 OB EB

      • 127 severe complications

      • 33 spinal hematoma, 32 cauda equina, 29 meningitis, 13 epidural abscess, 20 miscellaneous

      • Any complications in OB EB 1:25,000

      • Spinal hematoma in OB EB 1:200,000

        • Only in presence of severe coagulopathy

      • Cx typically caused by direct traumatic injury


    Cnb complications france

    CNB Complications- France

    • AuroyAnesthesiology 2002; 97: 1274

    • 10 months prospective audit in 98-99, 487 staff

    • General Population

      • 35,439SAB:

        • 2,5/10,000 peripheral neuropathy

        • 0,8/10,000 caudaequina

        • 0/10,000 central neuro event

      • 5,561EB

        • 0/10,000 peripheral neuropathy, caudaequina, central neuro event

      • Most resolved in 1 week, all resolved at 3 weeks

      • 75% had no paresthesia


    France cont d

    France cont’d

    • Obs Population

      • 5640 SAB

        • 3,5/10,000 peripheral neuropathy

        • 0/10,000 cauda equina or central neuro event

      • 29,732 EB

        • 0/10,000 peripheral neuropathy, cauda equina, or central neuro event

  • 12 X increased in RA in France over 16y


  • Trauma

    Trauma

    • To spinal cord, conus, spinal nerve roots

    • Direct needle/catheter trauma

    • Intraneuronal injection

    • Lirk AAS 2004, 48; 347

      • 82 consultants

      • 93.7% within 1 interspace on intended target (T8-L4)

      • 49% at it, 18% above, 28% lower


    Landmarks

    Landmarks

    • Cord terminates at L1 in 60%

    • Cord extends to L2-3 in 10%

    • Lower in women than in men

    • Tuffier’s line at L4 or L4L5 space

    • Kim Anesthesiology2003; 99: 1359

      • MRI 690 consecutive patients


    Postpartum neurological complications

    Kim


    Conus tuffier

    Conus-Tuffier


    Conus injury after sab in ob

    Conus Injury After SAB in OB

    • Reynolds Anaesthesia 2001; 56: 238

    • 6 OB cases of conus injury after SAB

    • All had pain on needle insertion

    • 3/6 had clear free flow CSF

    • MRI- cord of normal length

    • 5/6 syrinx same side as pain and persistent neuro deficit

    • Recommendations made

      • Below L3, halt advancement with pain, inject only if pain completely resolves


    Postpartum neurological complications

    TNS

    • Radicular pain without sensory/motor deficit

    • Onset 0-2days, duration 2-3 days

    • 0-37% incidence

    • Risk factors

      • Lidocaine, lithotomy, ambulatory, obesity

  • lower incidence in Obs pts (0-3%)

  • Sacral numbness after SAB, EB,CSE for CS described in several reports

  • Unclear etiology


  • Spinal epidural hematoma

    Spinal Epidural Hematoma

    • Extremely rare general population

      • Vandermeulen Anesth Analg 1994; 79, 1165

        • SAB 1:220,000

        • EB 1:150,000

        • 68% coagulopathy

        • 50% EB on removal of catheter

        • Back pain rare, radicular leg pain

        • Weakness 46%, numbness 14%, bowel/bladder dysfunction

        • Sx within 8h

  • No case report of spinal/epidural hematoma after SAB in Obs patients… until 2004 in Sweden…


  • Obs spinal hematoma

    Obs Spinal Hematoma

    • Ususally associated with identifiable coagulopathy

      • Scott + Hibbard, BJA 1990; 64: 537-retrospective

        • 1 hematoma:506,000 EB

      • Holdcroft + Gibberd BJA 1995; 75: 522

        • 0:13,007

      • Scott + Tunstall Int J Obstet Anesth 1995; 4: 133

        • 0:108,133 EB

    • Yeah but I had a “bloody tap”

      • If otherwise healthy parturient, it does not appear to increase the risk of spinal/epidural hematoma


    Hematoma

    Hematoma

    • Coumadin

    • SC heparin

    • IV heparin

    • Anti platelets Rx

    •  not frequent in Obs

    • covered somewhere else

      • ASRA guidelines

      • Horlocker RAPM 2003; 28:172


    Obs hematoma plts

    Obs Hematoma- plts

    • >100,000plts-> OK

    • <50,000plts-> high risk

    • In between…

    • Beilin et al, Anesth Analg 1996; 83: 735

      • Most would if > 80,000, not if <50,000


    Obs hematoma lmwh

    Obs Hematoma- LMWH

    • ASRA guidelines

      • Prophylactic

        • Wait 12h before catheter removal after LMWH

        • Next LMWH dose >2h post removal

        • Bloody insertion, wait >24h

        • Monitor neuro function

      • Therapeutic…


    Spinal infection

    Spinal Infection

    • Spinal epidural abscess (SEA)-rare in Obs anesth

      • Scott and Hibbard -1:506,000

      • Scott and Tunstall -0:108,133

      • Case reports of spontaneous SEA

      • Most common organism SEA Staph aureus

      • Sx 4-10 days PP

      • Severe backache most consistent Sx, localised tenderness (90%

      • Fever, leukocytosis, neck stiffness, H/A

      • Late Sx: radiating segmental pain, sensation loss of lower limbs/sacral, bladder dyfunction, decreased DTRs, weakness, paralysis

      • MRI, surgery, antibiotics


    Obs meningitis

    Obs Meningitis

    • Meningitis- also rare

      • SAB>EB

      • Several case reports of meningitis in CSE of L+D

      • 1-3 days PP, fever, H/A, neck stifness

      • Prognosis better than SEA as all had full recovery

  • Aseptic technique (gown, face mask)

    • Case reports of meningitis after SAB from anesthetists’ oral cavity

    • … but no reduction of surgical wound infections during clean surgery

    • Cleaning solutions

      • Iodophor in isopropyl alcohol (Duraprep) >poviodine

      • Chlorexhidine > poviodine


  • Cranial nerve palsies

    Cranial Nerve Palsies

    • Usually due to CSF leakage after DP, leading to mechanical trauma of cranial nerves due to stretching

    • Incidence: 1-4/100,000 obstetric RA

    • Abducens most frequent due to its long course

    • Also optic, trigeminal, facial, vestibulocochlear


    Postpartum neurological complications

    Plan

    • Cases

    • Mechanisms of Nerve Injury

    • Complications of Neuraxial Technique

      • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric Nerve Palsies

  • Evaluation of PP Neuro Complaint


  • Peripartum back pain

    Peripartum Back Pain

    • Common complaint of pregnancy and postpartum

    • Likely MSK, R/O neuro

    • Temporal association to neuraxial anesthesia

    • Both antepartum and postpartum BA around 50%

      • Russell, Reynolds BMJ1997; 314, 1062

  • Antepartum BA strongest predictor of PPBA

  • Other risk factors-

    • low back pain before or during pregnancy, physically heavy work, and multiple pregnancy, also unrewarding employment and younger age

  • 2 prospective and 1 RCT no association between PPBA and LEA (maybe short term back c/o)


  • Postpartum neurological complications

    PPBA


    Howell bmj 2002 325 357

    Howell BMJ 2002; 325; 357


    Postpartum neurological complications

    Plan

    • Cases

    • Mechanisms of Nerve Injury

    • Complications of Neuraxial Technique

      • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric Nerve Palsies

  • Evaluation of PP Neuro Complaint


  • Nerves of the pelvis

    Nerves of the Pelvis


    Peripheral nerves dermatomes sensory territory

    Peripheral nerves/dermatomes sensory territory

    • Lateral Femoral Cutaneous

      • Upper outer thigh

    • Femoral

      • Anterior thigh, medial lower leg

    • Sciatic/Peroneal

      • Lateral lower leg, foot


    Maternal obstetric palsy

    Maternal Obstetric Palsy

    • 1838- 1st description of PP foot drop

    • 1878- 1st description of PP femoral neuropathy

    • Vast majority of PP neuro injuries are due to intrinsic obstetric palsies

    • Historically associated with (Murray 1964, 1900’s

      • Primiparity (67%)

      • Cephalopelvic disproportion

      • Midforceps delivery(85%)

      • Vertex presentation(97%)

      • 88% unilateral

      • Most recovered, return to function at 3mo, but improved up to 2 years


    Palsies

    Palsies

    • Bademosi (Africa 1980), 34 cases, no CNB

      • Lumbosacral plexus injury with foot drop most common deficit (88%)

      • Followed in order: absent ankle jerk, femoral nerve injury, obturator nerve, spastic paraparesis,

      • 72% unilateral

      • 76% complete recovery

      • Major predisposing factor: prolonged labor

      • Direct pressure of fetal head on lumbosacral plexus and nerve trunks


    Incidence of maternal palsies

    Incidence of Maternal Palsies

    • Wide range, different studies

    • Sx resolved or improved in almost all patients


    Risk factors

    Risk Factors

    • Wong et al, Obstet Gynecol 2003; 101: 279

      • 6057 women, 1997-98

      • 56 (0.92%) new LE nerve deficit, 21 had motor deficit

      • Nulliparity, prolonged 2nd stage, assisted (forceps or vacuum) delivery increased risk

      • Maternal/fetal body habitus, mode of delivery, CNB no association with nerve injury

      • Median duration of nerve injury symptoms was 2 months


    Cnb risk factor

    CNB Risk Factor?

    • Ong et al A+A 1987; 66: 18

      • Increased frequency with anesthesia (CNB+GA)

      • CNB in higher risk group:

        • longer labor

        • more difficut labor

        • instrumental deliveries

    • CNB indirect role?

      • Associated with longer 2nd stage

      • L+D sensory block may not appreciate Sx of impending nerve injury and may not change body position


    Maternal positioning

    Maternal Positioning

    • Wong et al

      • Women with PP nerve injury->significant more time pushing in semi-Fowler/lithotomy position

  • Warner et al, Anesthesiology 2000; 93: 938

    • Surgeries in lithotomy

    • Nerve injury associated with time in lithotomy position

    • Not associated with patient body habitus or DM


  • Meralgia paresthetica

    MeralgiaParesthetica

    • Sensory monomeuritis of lateral femoral cutaneous nerve (L2-3)

    • Trauma or compression along its course

    • Most times at inguinal ligament

    • Usually begins at 30th weeks GA

    • Obesity, increased lumbar lordosis, increased IAP during S2 pushing, DM, hip flexion

    • Numbness, paresthesia of anterolateral thigh

    • Self-limited, resolved within 3 months after delivery


    Femoral neuropathy

    Femoral Neuropathy

    • Early 20th century, incidence 3.2%

    • Femoral nerve(L2-4)

    • Compression(stretching) at inguinal ligament by:

      • Hip flexion, external rotation, abduction, excessive lithotomy

  • But, if weak hip flexion, then more proximal lesion at iliopsoas level:

    • Obstetrics, instruments, selfretainin retractors during Pfannenstiel

  • Other Sx:

    • Quad weakness, absent knee jerk, decreased sensation

    • Cannot climb stairs or rise from squatting position


  • Obturator neuropathy

    Obturator Neuropathy

    • Obturator nerve (L2-4)

    • Compression between pelvis and fetal head or forceps

    • Usually unilateral and combined with femoral neuropathy

    • Weak hip adduction and internal rotation, sensory loss of medial thigh


    Lumbosacral plexus injury

    Lumbosacral Plexus Injury

    • Foot drop most common obstetric nerve palsy in middle 20th century

    • Lumbosacral trunk(L4-5) compressed between sacrum and fetal head of forceps

    • Risk factors:

      • Macrosomia, malpresentation or positions (OP or brow), straight sacrum, wide posterior pelvis, short stature

      • Prolonged labor and midforceps rotation

  • Foot drop, weak dorsiflexion, numbness on lateral foreleg and dorsum of foot (L5), almost always unilateral


  • Common peroneal neuropathy

    Common Peroneal Neuropathy

    • L4-S2

    • Similar presentation with lumbosacral injury

    • Knee hyperflexion, external forces (hands) on fibular head, stirrups, prolonged squatting during labor

    • Distinguish with nerve conduction studies


    Postpartum neurological complications

    Plan

    • Cases

    • Mechanisms of Nerve Injury

    • Complications of Neuraxial Technique

      • Trauma, TNS, hematoma, infections and others…

  • Peripartum Back Pain

  • Obstetric Nerve Palsies

  • Evaluation of PP Neuro Complaint


  • Clinical evaluation

    Clinical Evaluation

    • Principles

      • Determination of central VS peripheral lesions

      • Central lesions rare but catastrophic

      • Assessment complicated by common Obs comorbidities

        • Fever, urinary retention, incontinence, anal sphincter dysfunction common after childbirht

        • Bilateral Sx not always central lesions as bilateral nerve palsies reported

        • Intrinsic nerve palsies usually not painful

        • Neuraxial pathology usually associated with pain

      • Sx present immediately after L+D that have improved or stayed the same VS if worsening, or occurring after Sx-free interval


    History

    History

    • Onset

      • Preexisting, intra/postpartum

    • Mode of delivery

      • Vaginal, C/S

    • Instrumental delivery

      • Forceps used

    • Maternal positionning

    • Length of labor

    • Pain, location, radiation, bodily function/sphincter

    • Regional note to reread

    • Constitutional Sx: fever, white count


    Physical

    Physical

    • Differentiate central, radicular, plexus, peripheral nerve

    • Considerable overlap in sensory P/E of LE

    • Motor deficits might be more helpful

    • Back pain

    • Constitutional signs

    • Central VS peripheral helped by P/E paraspinous musculature

      • Don’t forget posterior rami also affected by nerve root damage

      • Low back sensation, muscle


    Investigations

    Investigations

    • MRI

      • Gold standard to r/o central lesions

  • EMG/NCS

    • site of injury, degree of axonal loss, prognosis

  • Neuropraxia

    • Slowed blocked conduction in segment, normal proximally/distally

    • Usually normal EMG

  • Axonotmesis/Neurotmesis

    • NCS progressive diminution of amplitude signal over 48-72h

    • EMG abnormal 2-3 weeks after injury


  • Case 31

    Case 3

    • 24yo multip, normal pregnancy, low back pain, bilateral leg pain

    • Uneventful labor, epidural placed mid stage 1, easy insertion, worked well

    • PPD 1, difficulty walking

    • Pain infra-umbilical, radiating into both legs, buttocks

    • Awkward antalgic, waddling gait

    • No motor, sensory or reflex deficit


    Symphysis pubis diastasis

    Symphysis Pubis Diastasis

    • Incidence unknown, 1:300-1:30,000

    • Fetal head exerts distending pressure on softened pelvic ligaments

    • Joint disrupted during vaginal delivery

    • Sx:

      • Suprapubic pain with radiation to legs, hips, back

      • Difficulty standing, walking, leg weakness

  • DI- XR, CT, MRI

  • Resolves within 3mo


  • Postpartum neurological complications

    Voilà!!!

    • THE END…


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