<p>Spinal Anesthesia for Amyotrophic Lateral Sclerosis Patient Undergoing Lower Extremity Orthopedic Surgery: An Overview of the Anesthetic Considerations</p>

Abstract

Background: Amyotrophic lateral sclerosis is a progressive neurodegenerative disease primarily affecting the upper and lower motor neurons. Patients present with a variety of clinical manifestations inevitably resulting in death secondary to respiratory insufficiency from muscle weakness and consequential pulmonary complications. Despite the lack of universal consensus on the ideal anesthetic approach to amyotrophic lateral sclerosis patients undergoing lower extremity total joint surgery, there are few noteworthy anesthetic considerations in this cohort. Case Report: A 75-year-old male with multiple medical comorbidities, including a recent diagnosis of amyotrophic lateral sclerosis, presented to a large academic medical center for a right total hip arthroplasty revision. The patient's preoperative neurologic examination demonstrated brisk deep tendon reflexes, visible fasciculations of lower extremities, and motor weakness of upper and lower extremities. Serology demonstrated an elevated creatine kinase, and an electromyography study showed active denervation in the cervical, thoracic, and lumbosacral regions. After a careful risk-benefit analysis was performed, involving a multidisciplinary team approach, the patient successfully underwent the surgical procedure with a spinal anesthetic and minimal sedation. Perioperative course was unremarkable, and there were no neurologic complications in the first 6 months after surgery. Conclusion: Patients with amyotrophic lateral sclerosis present unique challenges for anesthesia providers. General anesthesia may potentially worsen respiratory function; therefore, alternative methods to avoiding airway manipulation should be considered. Conversely, regional techniques may carry the risk of exacerbating pre-existing neurologic symptoms. Currently, no definite guidelines exist on the perioperative anesthetic management of amyotrophic lateral sclerosis patients; ultimately, the decision to perform regional anesthesia should be based on analyzing a patient's risk against the potential benefits.

Neuraxial and Regional Anesthesia in a Patient With Amyotrophic Lateral Sclerosis: A Case Report

“…Patients with ALS present unique challenges to the anesthesiologist [ 4 ]. Anesthetic concerns in these patients include gastric aspiration, postoperative ventilatory support, autonomic instability, and an unpredictable increased sensitivity to opioids, sedatives/hypnotics, and non-depolarizing neuromuscular blocking agents [ 5 ]. In addition to these considerations, previous case reports raised concern for the worsening of pre-existing neurologic symptoms with the use of regional anesthesia [ 6 , 7 ].…”

“…Anesthesiologists typically encounter patients with ALS for procedures related to their disease's progression such as gastrostomy and tracheostomy tube placement [ 4 ]. However, patients with ALS undergoing lower extremity joint replacement are rarely encountered, and no definitive guidelines exist for their perioperative care [ 5 ]. General anesthesia may worsen respiratory function and lead to prolonged invasive mechanical ventilation and other pulmonary complications [ 4 ].…”

“…Alternatively, regional anesthesia is traditionally avoided in patients with ALS, as it may worsen pre-existing neurologic symptoms [ 6 , 7 ]. However, there is growing support and evidence for the safe use of regional anesthetic techniques in patients with ALS [ 5 , 8 , 9 ].…”

Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review

“…However, there is a paucity of information regarding surgical outcomes for patients with ALS. 44 Surgery carries a significant risk of precipitating respiratory failure and the potential to worsen functional decline. 45 Perioperative pulmonary complications may occur for many reasons; atelectasis, residual effects of anaesthetic agents, side-effects of analgesics, the inability to compensate for complications such as aspiration and respiratory infection, and potential neuromodulation by the stress response and inflammation.…”

“…137 Reports of the use of spinal anaesthesia without complications exist for patients with ALS. 44,122 Specific caution will be needed to avoid a block height that impedes respiratory function. Despite concern, complication rates appear low in central neurological disease.…”