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  Table of Contents 
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 94-96

Neuromyelitis optica: An anesthetic challenge

Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission25-Aug-2020
Date of Acceptance11-Sep-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Ankur Sharma
Department of Anaesthesiology & Critical Care, AIIMS Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_135_20

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Neuromyelitis optica (NMO), a rare devastating demyelinating syndrome involving optic neuritis and myelitis, poses a challenge to anesthesiologists. Here, we present the anesthetic management of a diagnosed case of NMO posted for total hip replacement. Although literature documenting adverse outcomes with both general anesthesia (GA) and spinal anesthesia (SA), more so with SA, it should always be considered if benefits outweigh the risk of GA. An uneventful perioperative period in the previous two surgeries favored SA as an anesthetic technique for consecutively third time in this case with smooth recovery.

Keywords: Neuromyelitis optica, spinal anesthesia, total hip replacement

How to cite this article:
Rapeti KM, Paliwal B, Sharma A, Kamal M, Bhatia P. Neuromyelitis optica: An anesthetic challenge. Indian Anaesth Forum 2021;22:94-6

How to cite this URL:
Rapeti KM, Paliwal B, Sharma A, Kamal M, Bhatia P. Neuromyelitis optica: An anesthetic challenge. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:94-6. Available from: http://www.theiaforum.org/text.asp?2021/22/1/94/309745

  Introduction Top

Neuromyelitis optica (NMO) is a devastating demyelinating syndrome characterized by optic neuritis and myelitis, either simultaneously or in sequential relapses. The currently accepted diagnostic criteria for NMO is a history of optic neuritis and myelitis along with the presence of at least two of the three following findings: the presence of NMO IgG, an initial brain magnetic resonance imaging (MRI) negative for multiple sclerosis, and a contiguous spinal cord lesion greater than three vertebral lengths, otherwise known as a longitudinally extensive transverse myelitis.

  Case Report Top

A 38-year-old male patient with classical presentation of NMO symptoms over 8 years presented for total hip replacement (THR) surgery. He was apparently all right 8 years back when he developed tingling and stiffness in both his lower limbs which gradually increased over 5–6 days. He was relieved of symptoms after conventional treatment for 3 days. After 1½ years, he developed a painless blurring of vision in the right eye, followed by the same complaints in the left eye 18 months later. His vision improved gradually in both eyes with treatment. Subsequently, about 1 year from then, he developed tingling, numbness, and weakness in marching pattern in the left upper limb from the tip of fingers to the shoulder for around 1 month, followed by complete recovery. Pain in the bilateral gluteal region and weakness and numbness in both lower limbs for 20 days followed 2 years after resolution of the upper limb symptoms. MRI spine revealed C5–C6 diffuse disc bulge and cavity from cervicomedullary junction to C2 level, and there was focal syrinx. The patient gradually improved with treatment.

One year ago, he developed pain in both hip regions and was diagnosed to have bilateral avascular necrosis of the head of the femur. He underwent debridement of the right hip under spinal anesthesia (SA). Eleven months later, right THR was done under combined spinal and epidural anesthesia with 2.5 ml of 0.5% bupivacaine heavy and fentanyl 25 μg intrathecally. No postoperative relapses of NMO were observed in either of the surgeries under SA.

After explaining the potential risk of relapses of the disease after neuraxial anesthesia and of the postoperative respiratory support requirement after general anesthesia (GA), he opted for the neuraxial block for current surgery. He was given SA with injection 0.5% bupivacaine heavy 2.5 ml and injection fentanyl 25 μg. The intraoperative course and postoperative recovery were uneventful. The patient was monitored for 1 week and subsequently discharged home. No relapses were reported during the last 6 months of follow-up.

  Discussion Top

NMO is a rare demyelinating disease of the central nervous system that predominantly affects the optic nerves and spinal cord.[1] Among the Asian countries, the prevalence ranges from 2.6 per 100,000 (India) to 3.65 per 100,000 (Japan), which is higher compared with that for Caucasians.[2],[3] The female-to-male ratio is 9:1, with predominance during childbearing age.[4] This patient met the diagnostic criteria of NMO with optic neuritis, repeated episodes of acute myelitis, normal brain MRI, and pathological MRI findings in more than three vertebral segments. The patient had clinical improvement with steroids and autoimmune drugs.

The biggest challenge in the anesthetic management is the choice of anesthetic technique. Relapse of symptoms is reported with both neuraxial anesthesia[5],[6] and GA.[7] Direct neurotoxicity or an immuno-allergic reaction to bupivacaine is postulated as the cause of clinical deterioration in patients who received spinal bupivacaine. However, transverse myelitis has been reported 2 weeks after an uncomplicated general anesthetic as well.[6] In contrast, obstetric patients with NMO who received epidural anesthesia and analgesia have been found to have no aggravating effect on the disease.[8],[9] With regard to GA, there are concerns about increased neuromuscular junction response to muscle relaxants and incomplete recovery from neuromuscular blockade in patients with NMO. Respiratory weakness after extubation requiring positive airway pressure ventilation has been reported in these patients.[10]

Thus, disease progression with an anesthetic technique seems to be a temporal consequence rather than a cause–effect relationship and not to be attributed to the anesthetic technique itself.[6] The anesthetic management can thus be individualized with informed consent considering the risk–benefit ratio of GA and SA. This patient had undergone present surgery under SA considering the previous two operations under SA with no adverse effects postoperatively.

  Conclusion Top

Although the current literature is unequivocal for safer mode of anesthesia in patients with NMO, more of such case reports will help to reach a conclusion on the safer anesthetic technique. Although it is premature to say that aggravation of NMO after neuraxial anesthesia could be a temporal consequence, the present case adds as a supporting literature for safety and conduction of surgery under SA in patients with NMO.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wingerchuk DM, Banwell B, Bennett JL, Cabre P, Carroll W, Chitnis T, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology 2015;85:177-89.  Back to cited text no. 1
Pandit L, Asgari N, Apiwattanakul M, Palace J, Paul F, Leite MI, et al. Demographic and clinical features of neuromyelitis optica: A review. Mult Scler 2015;21:845-53.  Back to cited text no. 2
Daniëlle van Pelt E, Wong YYM, Ketelslegers IA, Siepman DA, Hamann D, Hintzen RQ. Incidence of AQP4-IgG seropositive neuromyelitis optica spectrum disorders in the Netherlands: About one in a million. Mult Scler J Exp Transl Clin. 2016;2:2055217315625652. doi:10.1177/2055217315625652.  Back to cited text no. 3
Flanagan EP, Cabre P, Weinshenker BG, Sauver JS, Jacobson DJ, Majed M, et al. Epidemiology of aquaporin-4 autoimmunity and neuromyelitis optica spectrum. Ann Neurol 2016;79:775-83.  Back to cited text no. 4
Hosseini H, Brugieres P, Degos JD, Cesaro P. Neuromyelitis optica after a spinal anaesthesia with bupivacaine. Mult Scler 2003;9:526-8.  Back to cited text no. 5
Facco E, Giorgetti R, Zanette G. Spinal anaesthesia and neuromyelitis optica: Cause or coincidence? Eur J Anaesthesiol 2010;27:578-80.  Back to cited text no. 6
Gutowski NJ, Davies AO. Transverse myelitis following general anaesthesia. Anaesthesia 1993;48:44-5.  Back to cited text no. 7
Gunaydin B, Akcali D, Alkan M. Epidural anaesthesia for Caesarean section in a patient with Devic's Syndrome. Anaesthesia 2001;56:565-7.  Back to cited text no. 8
Bourre B, Marignier R, Zéphir H, Papeix C, Brassat D, Castelnovo G, et al. Neuromyelitis optica and pregnancy. Neurology 2012;78:875-9.  Back to cited text no. 9
Sadana N, Houtchens M, Farber MK. Anesthetic management of a parturient with neuromyelitis optica. Int J Obstet Anesth 2012;21:371-5.  Back to cited text no. 10


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