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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.59 no.2 Campinas Mar./Apr. 2009
Combined spinal-epidural block in a patient with amyotrophic lateral sclerosis. Case report*
Anestesia combinada raquiepidural en paciente portadora de esclerosis lateral amiotrófica. Relato de caso
Adriano Bechara de Souza Hobaika, TSAI; Bárbara Silva NevesII
em Medicina, Anestesiologista do Hospital Mater Dei
IIME3 do CET/SBA Santa Casa de Belo Horizonte
OBJECTIVES: Amyotrophic lateral sclerosis starts between the fifth and sixth
decades of life, causing degeneration and death of upper and lower motor neurons.
When the muscles responsible for ventilation are affected, the patient dies
of respiratory failure within a few years.
CASE REPORT: This is a 63 years old female with amyotrophic lateral sclerosis who underwent surgical treatment of a transtrochanteric fracture of the femur. The patient presented weakness of upper and lower limbs and dysarthria, and she was awake and oriented. Respiratory function: ineffective cough, decreased strength of the intercostal muscles and diaphragm, and reduction of the breath sounds in both lung bases. Initially, the L3/L4 epidural space was punctured and a silicon catheter was introduced to 5 cm. This was followed by a spinal puncture in the L4/L5 space and the administration of 7.5 mg of hyperbaric bupivacaine. This was followed by the administration of 37 mg of 0.37% ropivacaine through the epidural catheter for a sensitive blockade up to T10. The procedure evolved without complications and the patient was discharged from the hospital after three days.
CONCLUSIONS: The evidence has demonstrated that neuroaxis blocks can be safely performed in patients with amyotrophic lateral sclerosis since it avoids manipulation of the airways and respiratory complications.
Key Words: ANESTHETIC TECHNIQUES, Regional: combined epidural-subarachnoid; DISEASES, Muscular: amyotrophic lateral sclerosis
Y OBJETIVOS: La esclerosis lateral amiotrófica es una enfermedad
que empieza entre la quinta y la sexta década de vida y que provoca la
degeneración y la muerte de las neuronas motoras superiores e inferiores.
Cuando los músculos responsables de la ventilación son acometidos,
el paciente evoluciona a óbito en algunos años debido a la insuficiencia
RELATO DEL CASO: Sexo femenino, 63 años, esclerosis lateral amiotrófica, sometida a tratamiento quirúrgico de fractura transtrocantérica de fémur. Cuadro de debilidad en los miembros superiores e inferiores, disartria, consciente y orientada. Aparato respiratorio: tos ineficaz, reducción de la fuerza de los músculos intercostales y diafragma y reducción del murmurio vesicular en bases pulmonares. Primeramente, la punción epidural fue realizada en L3/L4, donde un catéter de silicona fue introducido 5 cm. A continuación, la punción raquídea se hizo en L4/L5 con administración de 7.5 mg de bupivacaína hiperbárica. Más 37 mg de ropivacaína a 0,37% se administraron por el catéter epidural para que el bloqueo sensitivo llegase al dermatomo T10. El procedimiento transcurrió sin complicaciones y la paciente recibió alta tres días después.
CONCLUSIONES: Las evidencias han demostrado que la administración de bloqueos de neuro eje, parece ser segura en pacientes con esclerosis lateral amiotrófica, pues evita la manipulación de las vías aéreas y las complicaciones ventilatorias.
Amyotrophic lateral sclerosis (ALS) starts between the fifth and sixth decades of life, causing degeneration and death of the upper (cerebral cortex and brain stem) and lower (spinal cord) motor neurons. Progressive denervation affects the muscles, causing weakness and atrophy, but the intellect is preserved. When the muscles responsible for ventilation are affected, death, due to respiratory failure, occurs within a few years 1. This disorder does not have a specific treatment, and riluzole, recently approved by the Food and Drug Administration, reduces neuronal degeneration and prolongs survival by a few months.
This is a 63 years old female patient with ALS and hypertension scheduled for surgical repair of a transtrochanteric fracture of the femur. Her medications included: vimpocetine, riluzole, acetyl salicylic acid, and enalapril maleate. She presented weakness of the upper and lower limbs, dysarthria, and she was awake and oriented. Preoperative exams and coagulograma were normal. Respiratory tract: ineffective cough, decreased strength of intercostal muscles and diaphragm, and reduced breath sounds in both bases.
The patient was sedated with midazolam (1 mg) and underwent combined neuroaxis block. First, epidural puncture was performed in the L3/L4 space and a silicon catheter was introduced to 5 cm. This was followed by a spinal puncture in the L4/L5 space with the administration of 7.5 mg of hyperbaric bupivacaine. Another 37 mg of 0.37% ropivacaine were administered through the epidural catheter to achieve a sensitive block up to the T10 dermatome. Additional medications included: dexamethasone (10 mg), ondansetron (4 mg), and cefazolin (2,000 mg). The procedure was performed without complications and the vital signs of the patient remained stable. The patient was discharged from the hospital after three days.
Respiratory failure is the main cause of death in patients with ALS 2. This represents the main risk when administering general anesthesia and neuromuscular blockers in those patients, since they can increase the weakness of the respiratory muscle 4. Prolonged paralysis and residual neuromuscular blockade can complicate tracheal intubation. For this reason, one may choose awake intubation and the administration of small doses of neuromuscular blockers, or none at all 5. In fact, those patients may have increased sensitivity to those drugs, and monitoring the neuromuscular function is mandatory. Patients with disrupted medulla can also present prolonged apnea after general anesthesia 6.
Although neuroaxis blocks are not contraindicated, there is always the fear that the administration of the local anesthetic close to the nerve could exacerbate pre-existing disease symptoms 7. However, the evidence has demonstrated that those blocks seem to be safe in those patients, since they avoid manipulation of the airways and respiratory complications 7-10. In an innovative study, Kitoh et al. administered epidural block associated with the blockade of lumbar sympathetic ganglia for the treatment of ALS in a patient and observed improvement of the symptoms of the affected lower limb 11.
Only two reports on subarachnoid blocks in ALS patients were found: an exploratory laparotomy 3 and a cesarean section 12, which were not associated with complications.
In the patient presented here, a combined block was used. Heavy bupivacaine was used in the subarachnoid block due to the shorter duration of action when compared with the isobaric form. Ropivacaine at 0.37% was used for the epidural block since it provides adequate sensitive blockade and reduced motor blockade 13. Using the combined technique enabled early monitoring of the motor function of the lower limbs. Reduced doses of sedatives were administered because the titrated use of sedatives has been recommended and, if possible, avoided due to the risk of worsening respiratory function.
The patient was being treated with riluzole and vimpocetine. Vimpocetine has cerebral vasodilation and neuroprotective action, inhibiting voltage-dependent sodium and calcium channels and the cell reuptake of adenosine. The drug is indicated in the treatment of symptoms of cognitive deterioration associated with cerebral vascular diseases. Riluzole has several mechanisms of action: it blocks sodium channels and high-voltage calcium channels, and it is an antagonist of NMDA/glutamate receptors. The blockade is exerted, especially, on tetrodotoxin-sensitive sodium channels (TTX-S), which are associated with neuronal lesion. The interaction between those drugs and anesthetics has not been reported.
This was the report on a patient with amyotrophic lateral sclerosis who underwent surgical treatment of a femur fracture under combined spinal-epidural block without complications.
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02. Gregory SA - Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation, 2007;22:435-443. [ Links ]
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07. Hara K, Sakura S, Saito Y et al. - Epidural anesthesia and pulmonary function in a patient with amyotrophic lateral sclerosis. Anesth Analg, 1996;83:878-879. [ Links ]
08. Kochi T, Oka T, Mizuguchi T - Epidural anesthesia for patients with amyotrophic lateral sclerosis. Anesth Analg, 1989;68:410-412. [ Links ]
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10. Chen LK, Chang Y, Liu CC et al. - Epidural anesthesia combined with propofol sedation for abdominal hysterectomy in a patient with amyotrophic lateral sclerosis - a case report. Acta Anaesthesiol Sing, 1998;36:103-106. [ Links ]
11. Kitoh T, Kobayashi K, Ina H et al. - Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS). J Anesth, 2006;20:109-112. [ Links ]
12. Moret JE, Di Gioia M, Montaruli V - Subarachnoid anesthesia in a case of cesarean section in a 27-year old patient with amyotrophic lateral sclerosis, in the 39th week of pregnancy. Minerva Anestesiol, 1991;57:747-748. [ Links ]
13. Casati A, Santorsola R, Cerchierini E et al. - Ropivacaine. Minerva Anestesiol 2001;67(suppl 1):15-19. [ Links ]
Correspondence to: Submitted em 28
de maio de 2008 *
Received from do CET/SBA Santa Casa de Belo Horizonte, MG
Dr. Adriano Bechara de Souza Hobaika
Rua Desembargador Jorge Fontana, 214/1601 - Belvedere
30320-670 Belo Horizonte, MG
Accepted para publicação em 29 de dezembro de 2008
Submitted em 28
de maio de 2008
* Received from do CET/SBA Santa Casa de Belo Horizonte, MG