Epidural analgesia in an obstetric patient with an intradural lipoma

Introduction

Intradural lipomas are rare, accounting for less than 1% of all spinal tumours [1, 2]. Most are located posterior to the cord in the cervical and thoracic regions [1, 3]. Patients may be asymptomatic or symptomatic, requiring surgical intervention [3]. Patients presenting with intradural lipomas in pregnancy pose a challenge to anaesthetists. There is sparse literature available to guide the use of neuraxial techniques in these patients. This report describes a patient with a cervical intradural lipoma presenting during pregnancy who received epidural analgesia.

Report

The patient is now a 24‐year‐old primiparous woman with a background of asthma and joint hypermobility syndrome. As a teenager, she underwent an orthopaedic procedure under general anaesthesia with no issues. She had a magnetic resonance imaging (MRI) of her spine in 2017 to investigate possible scoliosis. This showed a 3 cm intradural lipoma at the level of C6‐T1, along with a cutaneous lipoma in the thoracic region (Fig. 1). There was no signal cord change or cord compression. She remained under surveillance by a neurosurgical team who organised a repeat MRI in 2018 which showed no interval change. She had largely been asymptomatic, other than experiencing intermittent headaches, which decreased in duration and intensity during pregnancy.

Figure 1.

Sagittal high MRI cervical spine showing intradural lipoma at the level of C6‐T1. MRI, magnetic resonance imaging.

At 33 weeks gestation, she was advised in an obstetric anaesthetic clinic that neurosurgical input was needed to determine the safety of neuraxial techniques. If contraindicated, any operation would require a general anaesthetic. The main concern was that pressure changes resulting from epidural top‐up or dural puncture could result in movement of the lesion and impedance to flow of cerebrospinal fluid, potentially causing an unpredictable block or neurological complications. There was uncertainty about her anaesthetic management as there was little information in the medical literature regarding neuraxial techniques in pregnant women with intradural lipomas.

The neurosurgical team advised there was no contraindication to neuraxial techniques. She underwent induction of labour at 38 weeks gestation for pregnancy‐induced hypertension. An epidural was inserted uneventfully and provided effective analgesia during labour and birth. She had a standard anaesthetic follow‐up 2 days after delivery and at 3 months post‐partum, with no complications identified.

Discussion

The importance of understanding the nature of the spinal lesion and anatomical abnormalities is essential to providing safe neuraxial anaesthesia and analgesia for women in labour [4]. For example, epidurals may be performed at levels where an intact ligamentum flavum is present but may provide incomplete analgesia if the integrity of the epidural space is altered [4]. It is likely that significant interpatient variability will exist, therefore clinical and radiological assessments are essential to guide anaesthetic management options. Seeking advice from the neurosurgical team was invaluable in providing reassurance to the patient and the anaesthetic team.

Patient perspective

When the patient was first seen in the anaesthetic clinic, she was concerned her intradural lipoma would limit her pain relief options in labour and that she may be limited to a general anaesthetic, if surgery was required. Following neurosurgical input and a further discussion with the anaesthetic consultant, she felt reassured that she could receive standard anaesthetic care. During labour, she found the epidural provided excellent pain relief.