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
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
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.
- Absence of melanoma outside the CNS.
- Histopathological confirmation3.
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
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.