Managing ALS at the End of Life: An Exploration of Anesthetic Considerations and Palliative Care

Introduction 

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that includes both upper motor neuron and lower motor neuron dysfunction. Lower motor neuron signs can present as flaccid limb weakness, fasciculations, atrophy, and bulbar palsy. Late symptoms can include autonomic symptoms. Life threatening symptoms include respiratory failure and dysphagia that can result in aspiration pneumonia(1,2). The cause of ALS is poorly understood, but there are familial cases characterized by genetic mutations in genes such as a SOD1(2), leading to increased free radical damage to neurons or C9orf72, leading to a loss or gain of function of the resultant protein.

Patients with ALS pose unique challenges regarding anesthetic considerations. Here, an eventful case of spinal anesthesia/pain management in advanced ALS can help guide recommendations for future spinal anesthesia use.