title: Anesthesia for Cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord.
abstract: OBJECTIVE
  Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case.
  
  
  METHODS
  The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia.
  
  
  CONCLUSIONS
  Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.
authors.affiliation: Department of Anesthesia, Tripler Army Medical Center, Hawaii 96859-5000, USA. Brian_P.Jones@TAMC.CHCS.AMEDD.ARMY.MIL
authors.forename: B P
authors.initials: BP
authors.lastname: Jones
authors.forename: B C
authors.initials: BC
authors.lastname: Milliken
authors.forename: D H
authors.initials: DH
authors.lastname: Penning
mesh_terms: D000328:Adult; D000773:Anesthesia, Obstetrical; D002585:Cesarean Section; D005260:Female; D006801:Humans; D010264:Paraplegia / Q000209:etiology* / Q000503:physiopathology; D011225:Pre-Eclampsia / Q000503:physiopathology; D011247:Pregnancy; D011252:Pregnancy Complications, Neoplastic / Q000503:physiopathology*; D013120:Spinal Cord Neoplasms / Q000150:complications / Q000556:secondary*