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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 109-111

Ultrasonography in aid of spinal anaesthesia in lumbar lipomas not infallible


1 Consultant Anesthesiologist, Ruby Hall Clinic, Pune, Maharashtra, India
2 Fellows in Regional Anaesthesia, Ruby Hall Clinic, Pune, Maharashtra, India

Date of Submission11-May-2020
Date of Acceptance21-May-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Nita D'souza
Consultant Anesthesiologist, Department of Anaesthesia, 7th Floor Cancer Building, 40, Sassoon Road, Ruby Hall Clinic, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacc.JOACC_40_20

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  Abstract 


Lipomas are benign tumours which are frequently seen, however there is no specific mention regarding the incidence of lumbar lipomas. Literature does not describe challenges of anaesthesia technique in patients with lumbar lipomas without neuro deficit. An ultrasound examination of the spine using a low frequency probe contributes to screening for the path for passage of the needle.

Keywords: LSCS emergency, lumbar lipoma, ultrasound spine.


How to cite this article:
D'souza N, Karachiwala T, Kulkarni P. Ultrasonography in aid of spinal anaesthesia in lumbar lipomas not infallible. J Obstet Anaesth Crit Care 2021;11:109-11

How to cite this URL:
D'souza N, Karachiwala T, Kulkarni P. Ultrasonography in aid of spinal anaesthesia in lumbar lipomas not infallible. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Dec 9];11:109-11. Available from: https://www.joacc.com/text.asp?2021/11/2/109/327408




  Introduction Top


Lipomas are benign fatty tumours that grow just below the skin, most less than 5 cms in size with a predisposition to neck, forearm, shoulder, thighs and arms. Though rare, these may occasionally appear on the back too. A confirmation is based on physical examination, excision biopsy or radiological imaging. A pregnant patient with a lumbar lipoma for emergency caesarean section gives us limited options for complete and thorough imaging. Case reports of patients with spinal dysraphisms have been reported, including one where epidural catheter was inserted through lipoma, however to our knowledge, this is the first report of spinal anaesthesia in a patient with lipoma at the site.[1],[2],[3]


  Case Top


A 32-year-old, primigravida presented for an emergency caesarean section. She was 76 kgs (BMI 30.8) and of average built. She denied any significant past medical conditions. A pre-anaesthetic check revealed a lipoma in the midline over the lumbar spine. This lipoma had a dimple, and existed since birth. It had progressively, though gradually grown over time. On physical examination there was a non-tender mass measuring approximately 10 × 12 cms in the midline lower back 12-13 cms above the upper end of the gluteal cleft, extending from T12 to L3 vertebra level. In the space coinciding with the intercristal line, the spinous process could be felt with deep palpation. The lower end of the lipoma overlapped with the intercristal line [Figure 1]a.
Figure 1: (a) The lumbar lipoma in sitting position. (b) The sacculated appearance of the lipoma on ultrasound scanning. (c) The arrow showing the posterior dura that can be clearly visualised

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Her neurological examination was unremarkable. An earlier work-up of this mass with an MRI (10-15 years back) had confirmed it as a lipoma. The attending neurologist had reassured and recommended against any need for further evaluation or intervention. In the current scenario we refrained from further investigations of the spine considering an emergency LSCS and planned to do an ultrasound scanning of the lower back.

The anaesthetic options were discussed with the patient. We planned ultrasound screening of the lumbar area over the mass to look into a clear path for the spinal needle and note the depth of the dura. This would help identify the posterior dura without significant distortion of anatomy of the superficial layers. We used a low frequency (3-5 Hz) curvilinear probe of the Mindray© machine with a depth of 10 cms. Scanning over the lipomatous mass revealed a clearly demarcated saculated mass (depth of around 4 cms) in the subcutaneous area [Figure 1]b without any involvement of the dura and posterior elements.

The interspinous space was scanned with the probe's long axis placed in the saggital plane on the lower margin of the lipoma to identify the spinous processes of two consecutive lumbar vertebrae. On ultrasound of the spine with the probe placed transverse, we were able to confirm the midline, the space that we would opt (L4-5) and the angulation needed of the spinal needle to get a direct puncture of the subarachnoid space. [Figure 1]c This point was marked with a skin-marker and under all aseptic precautions local anaesthetic was administered. We used a 25 G Whitacre spinal needle after administration of a local anaesthetic with a 26 G hypodermic needle in the space which was marked. A single, non-traumatic puncture of the dura was performed and drug 0.5% heavy Bupivacaine 10 mg with 12.5 mcg Fentanyl was injected after clear and free flow of CSF. The depth and angulation of the tap was consistent with our pre procedure USG scanning of the spine (the posterior complex at 5 cms on USG).

To our dismay, despite above efforts the patient had partial action of the spinal anaesthetic even after 10 minutes. We further decided to go ahead with administering general anaesthesia with Inj. Propofol 2 mg/kg, Inj. Succinylcholine 1 mg/kg with Oxygen + Sevoflurane and secured her airway with a 7 no. cuffed endotracheal tube. Inj. Fentanyl 1.5 mcg/kg was administered after the baby was delivered. Patient was administered an anterior quadratus lumborum block bilaterally prior to extubation. No residual spinal anaesthesia effect was noted post postoperative. Patient was pain free for 36 hours on follow up with routine Inj. Paracetamol 1 m BD and Inj. Diclofenac 75 mg I.V., BD. alternating 6 hourly. No untoward complication was noted and patient was comfortably discharged on the fourth post operative day. A 6 month follow up also revealed a healthy adult with routine life style.


  Discussion Top


Anaesthesiologists would usually avoid neuraxial anaesthesia in patients with anatomical and functional deficits secondary to spinal dysraphisms. A dimple on the spine, presence of a lipomatous lesion may be present in 70% patients with cord abnormalities of which 30% present with clinical features.[4] Epidural and spinal anaesthetic has been described in these cases with high failure rate and complications.[5] Closed spinal dysraphisms without symptoms would pose a challenge to the anaesthesiologist; that is a possibility of encountering patients who present with anatomical abnormality but not functional may pose a dilemma in deciding the plan of anaesthesia. MRI in such patient would give a clear picture of the involvement of the spinal cord after excluding the presence of a tethered cord, scarring or septae. Despite all this epidural spread of the local anaesthetic may be not as desired owing to septae or anatomical variations.

Lumbosacral lipomas are rare and on reviewing literature not much has been documented about their incidence or asymptomatic presentation. These fat-filled swellings are generally benign in nature but have a continuation that may go deep causing to connect with the spinal cord, filum terminale or cauda equina which may possibly interfere with neurological conduction and present with neuro deficits. This could be due to ischaemia due to traction on the neural structures during growth or owing to increase in the pressure proportionate to the fat content within the thecal sac. There have been reports in literature of pregnant patients who were operated in the past with spinal cord deformities (spina bifida, meningomyelocoel, etc.) who have further come for LSCS. Permanent neurologic deficit in these patients who have been operated before is rare.[6] Though the patient had been evaluated with an MRI 10-15 years back, new anatomical changes may appear owing to growth of the lipoma and some septae that may have cause the local anaesthetic spread to be patchy.

Presence of a lumbar lipoma does not exclude the use of neuraxial anaesthetic techniques, though each case must be individualised. Successful management would require radiological assessment, planning anaesthesia techniques meticulously and provisions for safe and pain free post operative course in a parturient. Spinal anaesthesia may be partial even in asymptomatic lumbar lipomas due to alterations in anatomy that may not be clearly visible on ultrasonographic scanning of the spine.

Thus, a recent MRI of the spine should be considered to minimise failure of neuraxial technique. Pregnant patients benefit from a spinal anaesthetic in view of their physiology, it remains the first choice unless the surgery or pathology of the patient warrants general anaesthesia. Ultrasound is a widely used and efficacious modality to guide injections about the spine but has its limitations as the waves are attenuated due to ultrasound waves passage through soft tissue and phase aberration.[7],[8] Lesions on the back pose as relative contraindications to neuraxial anaesthetic and can be managed with general anaesthesia and truncal blocks to facilitate pain free postoperative period and enhance recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cooper M, Sethna N. Epidural analgesia in patients with congenital lumbosacral spinal anomalies. Anesthesiol 1991;75:370-4.  Back to cited text no. 1
    
2.
Richmond D, Zaharievski I, Bond A. Management of pregnancy in mothers with spina bifida. Eur J Obstet Gynecol Reprod Biol 1987;25:341-5.  Back to cited text no. 2
    
3.
Saied NN, Helwani M. Successful lumbar epidural catheter placement through a lower back lipoma. Saudi J Anaesth 2013;7:83-5.  Back to cited text no. 3
    
4.
Gambling D, Douglas M, McKay R. Obstetric Anaesthesia and Uncommon Disorders Section 3: Nervous System Disorders, Cambridge University Press, 2nd Edn. Ch 9; 2008. p. 167–89.  Back to cited text no. 4
    
5.
Murphy CJ, Stanley E, Kavanagh E, Lenane PE, McCaul CL. Spinal dysraphisms in the parturient: Implications for perioperative anaesthetic care and labour analgesia. Int J Obstet Anesth 2015;24:252-63.  Back to cited text no. 5
    
6.
Hebl JR, Horlocker TT, Schroeder DR. Neuraxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg 2006;103:223-8.  Back to cited text no. 6
    
7.
Ahmed AS, Ramakrishnan R, Ramachandran V, Ramachandran SS, Phan K, Antonsen EL. Ultrasound diagnosis and therapeutic intervention in the spine. J Spine Surg 2018;4:423-32.  Back to cited text no. 7
    
8.
Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav V. Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology 2011;115:94-101.  Back to cited text no. 8
    


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