This is a case of a symptomatic Arnold Chiari malformation in
a gravid female with a suspected difficult airway. The patient is
a 28 year-old Gravida 1 Para 0 who was referred from an outside institution.
Her past medical history is significant for a previously unknown
asymptomatic Type I Arnold Chiari malformation that recently became
symptomatic after a motor vehicle accident one year prior. Since
the accident she has experienced headaches, upper extremity/neck
paresthesias, and multiple pre-syncopal events while performing
her activities of daily living. She is no longer able to cough,
defecate, or extend her neck without becoming symptomatic. She is
pregnant and has been evaluated by neurosurgery with the recommendation
of delaying any surgical intervention until after delivery. Her
obstetrical team was going to schedule a primary elective c-section
in order to prevent her from pushing. An anesthesiology consultation
was obtained and the patient was suspected to be a difficult airway.
She was thus transferred to a tertiary care facility for further
The patient was seen in the anesthesia pre-admission testing
clinic for evaluation. On further questioning it was uncovered
that the patient experienced symptoms including mild upper extremity
paresthesias, occipital headaches, and dizziness, and syncopal events.
She would become symptomatic with minor extensions of her neck,
with supine positioning, during valsalva maneuvers (such as having
bowel movements, coughing, or laughing), or with minimal exertion. Her
pregnancy has been otherwise uncomplicated.
On review of systems, she has been troubled by persistent GERD
throughout pregnancy that is being treated with antacids. The only
other medicine she takes is a daily multi-vitamin. She has not had
a previous anesthetic and denies family history of anesthetic complications
or malignant hyperthermia.
On physical exam, the patient was a thin gravid female. Paresthesias
and headaches were able to be elicited with minor neck extension
and supine positioning. She had a Mallampati IV airway with less
than 2 finger breadths mouth opening, prominent front incisors,
2 finger breadths thyromental distance, inability to extend her
jaw, and was unable to extend her neck secondary due to Chiari symptoms.
The rest of her physical exam was unremarkable.
After discussion with the patient regarding risks and benefits
to the different methods of providing anesthesia for a c-section,
the plan was formulated to attempt a single shot spinal block with
the smallest diameter needle available. In the event a spinal block
was unable to be performed, a general anesthetic with an awake fiber
optic intubation was planned.
The night prior to the patient’s scheduled c-section,
she presented in early spontaneous labor and was taken to the operating
room for a c-section. The anesthesia team on at that time was able
to successfully place a spinal bloc using a 25G pencil-point needle
(after one unsuccessful attempt with a 27G pencil-point) containing
1.5ml of hyperbaric 0.75% bupivacaine with an epinephrine wash,
100 mcg of preservative free morphine sulfate, and 10 mcg of fentanyl.
The patient experienced minor symptoms during delivery of the infant,
but otherwise remained asymptomatic throughout the procedure.
This case was difficult for a number of reasons. First, given
the fact the patient has a severely symptomatic Chiari malformation
that is currently unable ...