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Anesthetic Management of a Parturient With Primary Spinal Malignant Melanoma: A Case Report and Review of the Literature

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Anesthetic Management of a Parturient With Primary Spinal Malignant Melanoma
Shahenaz Elsamragy, MBBCh; Niyant Jain, MD; Rovnat Babazade, MD; Rakesh Vadhera, MD; Michelle Simon, MD; Mohamed Ibrahim, MD.
 Department of Anesthesiology, UTMB, Galveston, Texas

Introduction

-Primary CNS malignant melanomas are quite rare
-They account for 1% of all CNS tumors1.
-The potential presence of spinal cord malignancies is worrisome when considering neuraxial techniques due to possible complications4.
-Additionally, a history of cervical spine surgery is a cause of concern in airway management2  especially in an obstetric patient.
 

Literature Review

•Our review of the literature for similar case reports resulted in 58 total cases, the oldest being reported in 1906 by Hirschberg.
•Most of these cases were in the cervical and thoracic region of the spine.
•Only two of these cases were reported in pregnant patients (Yamamoto et al, 1975) and (Westergaard et al, 2017).
•Neither of the case reports discussed anesthetic considerations or management.
 

Case Report

A 30-year old patient was scheduled for an elective repeat cesarean section at 37 weeks.

She had undergone a previous cesarean section under general anesthesia at 31 weeks for worsening neurological symptoms caused by  a malignant melanoma of the cervical spine, levels C1-C3.

She had postoperative dyspnea and quadriparesis upon extubation requiring surgical tumor resection followed by irradiation of the surgical bed.

The patient had regular follow-up cervical MRIs since then.

 At 6 weeks of her following pregnancy , her MRI showed findings at C3-C4 possibly suggestive of malignancy.

A follow-up MRI a few months later showed similar findings but any neurosurgical interventions were postponed until clearer, contrast-enhanced studies were obtained after delivery.

Our main concern was airway manipulation because of her history and the presence of some limitation of her neck movement, in addition to being an obstetric patient.

The patient also requested spinal anesthesia because of her previous traumatic experience.

We therefore recommended a spinal anesthetic

However…..

This is a rare malignancy with an unpredictable course due to limited available data and her cervical MRI findings were not conclusive but were cause for concern.

So we requested a lumbar MRI to exclude suspicion of the malignancy in the lumbar region before proceeding.

Unfortunately, her lumbar MRI findings were highly suggestive of leptomeningeal malignancy.

Delivery date was moved up earlier to enable further investigations and treatment.

 We reconsidered our initial decision in favor of general anesthesia to avoid causing any complications by interfering in an area of the dura with a possible malignancy.

Imaging studies done after delivery supported the initial impression of recurrence of malignancy, in addition to the detection of metastatic findings in her brain MRI.

 

Discussion

 
•The diagnosis of primary CNS malignant melanomas is done by using Hayward’s criteria, the most important of which are:

- Absence of melanoma outside the CNS.

- Histopathological confirmation3.

•Regular annual MRIs and follow-ups are recommended after treatment due to this rare tumor's unpredictable course.
•Different complications with neuraxial anesthesia in the presence of a spinal cord malignancy include:
-Failure to achieve an adequate block or a unilateral block.
-Development of postoperative neurological deficits.
-A possible risk of ‘seeding’ malignant cells further into the neuroaxis5.

Therefore despite our initial decision, we decided to opt for general anesthesia, based on the MRI findings

 

Conclusion & Learning points

- A lumbar MRI is not a common preoperative anesthetic request, however, adequate preoperative investigations are necessary especially when dealing with a rare medical condition.

- Neuraxial anesthesia seemed like the best choice initially in this case but benefits have to be weighed against the possible risks in the presence of a potential spinal malignancy

 

References

1.Bucklin BA, Tinker JH, Smith CV. A patient with postdural puncture headache and acute leukemia. Anesth Analg 1999;881:166–7.
2.Crawly SM, Dalton AJ. Continuing Education in Anaesthesia Critical Care & Pain, Volume 15, Issue 5, 1 October 2015, Pages 253–257.
3.Hayward RD. Malignant melanoma and the central nervous system. A guide for classification based on the clinical findings. J Neurol Neurosurg Psychiatry. 1976;39(6):526-30.
4.Hung PC, Fan KT, Lai HC, Shen CH, Luk HN. Postoperative paraplegia as a result of undiagnosed primitive neuroectodermal tumor, not epidural analgesia. J Chin Med Assoc 2007;70:456–9

Jones BP, Milliken BC, Penning DH. Anesthesia for cesarean section in a patient with paraplegia resulting from tumor metastases to spinal cord. Can J Anaesth, 47 (2000), pp. 1122-1128.

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