What are the perioperative management considerations for patients with multiple sclerosis (MS) undergoing surgery?

Perioperative Management of Multiple Sclerosis

Patients with multiple sclerosis can safely undergo surgery with both general and regional anesthesia, and contrary to historical concerns, surgery itself does not appear to increase relapse risk when appropriate perioperative precautions are taken.

Key Perioperative Principles

The fundamental goals in managing MS patients perioperatively mirror those for other high-risk populations: maintain physiologic stability, avoid known triggers of disease exacerbation, and optimize baseline disease control 1.

Preoperative Assessment and Optimization

Disease Activity and Baseline Function:

• Document current neurological deficits, disease activity status (relapsing vs. progressive), and recent relapse history 1
• Assess functional status including mobility, bladder/bowel function, and respiratory capacity 1
• Review current disease-modifying therapies and their implications for surgery 1
• Evaluate for MS-related complications: autonomic dysfunction, respiratory muscle weakness, bulbar dysfunction 1

Surgical Timing Considerations:

• Elective surgery should ideally be performed during periods of disease stability, not during active exacerbation 2
• However, surgery can be performed during exacerbation when necessary with appropriate anesthetic depth 2
• Consider delaying elective procedures if patient has had recent relapse (within 3-6 months) to allow for recovery 3

Relapse Risk: The Evidence

The most recent and highest quality evidence demonstrates that surgery and anesthesia do not increase MS relapse risk. A 2020 study of 281 MS patients undergoing 609 surgeries found no increased odds of postoperative versus preoperative relapse (OR = 0.66,95% CI 0.20-2.16, p = 0.49) 4. This contradicts older case reports suggesting perioperative prophylaxis is necessary 3.

Despite this reassuring data, the surgical stress response remains a theoretical concern, and some practitioners advocate for perioperative prophylaxis in select high-risk patients 3.

Anesthetic Management

General Anesthesia

Both general and regional anesthesia have been used successfully in MS patients 1, 4.

Induction and Maintenance:

• Sevoflurane is well-tolerated and has been specifically studied in MS patients, including those in exacerbation 2
• Standard induction agents (propofol, etomidate) are safe 1
• Volatile anesthetics (sevoflurane, isoflurane) are appropriate for maintenance 2
• Adequate anesthetic depth is crucial, particularly in patients with active disease 2

Neuromuscular Blocking Agents:

• Avoid succinylcholine due to risk of hyperkalemia in patients with denervation or muscle atrophy 1
• Non-depolarizing agents (rocuronium, vecuronium, cisatracurium) are safe but may have prolonged duration in patients with significant muscle weakness 1
• Use nerve stimulator monitoring to guide dosing and reversal 1

Regional Anesthesia

Regional techniques are not contraindicated in MS patients, though historical concerns about exacerbating demyelination persist 1.

Neuraxial Anesthesia:

• Both spinal and epidural anesthesia have been used successfully 1
• Use lowest effective concentration of local anesthetic 1
• Document pre-existing neurological deficits thoroughly before procedure 1
• Consider avoiding neuraxial techniques in patients with significant spinal cord involvement or active spinal lesions 1

Peripheral Nerve Blocks:

• Generally considered safer than neuraxial techniques 1
• Use ultrasound guidance to minimize trauma 1
• Avoid high concentrations of local anesthetics 1

Intraoperative Management

Physiologic Monitoring and Maintenance

Temperature Control:

• Maintain strict normothermia; hyperthermia can worsen MS symptoms (Uhthoff's phenomenon) 1
• Use active warming devices cautiously, monitoring core temperature continuously 1
• Avoid excessive warming that could raise body temperature above baseline 1

Hemodynamic Management:

• Maintain adequate perfusion pressure to prevent spinal cord ischemia 1
• Be aware of autonomic dysfunction that may cause hemodynamic instability 1
• Avoid hypotension, particularly in patients with baseline neurological deficits 1

Ventilation:

• Ensure adequate oxygenation and ventilation 1
• Be prepared for potential respiratory muscle weakness requiring prolonged ventilatory support 1
• Consider arterial blood gas monitoring in patients with significant respiratory compromise 1

Medication Considerations

Continue Disease-Modifying Therapies:

• Most disease-modifying therapies (interferons, glatiramer acetate, oral agents) can be continued perioperatively 1
• Coordinate with neurology regarding immunosuppressive agents and infection risk 1
• Corticosteroids should be continued or stress-dose steroids given if patient is on chronic therapy 1

Avoid Specific Medications:

• Avoid medications that may worsen MS symptoms or precipitate relapse 1
• Use caution with drugs that lower seizure threshold in patients with seizure history 1

Postoperative Management

Immediate Recovery

Monitoring and Support:

• Extended monitoring may be needed for patients with significant baseline deficits 1
• Assess neurological function as patient emerges from anesthesia 1
• Ensure adequate respiratory function before extubation in patients with bulbar or respiratory muscle involvement 1

Pain Management:

• Multimodal analgesia is preferred to minimize opioid requirements 1
• Regional techniques (peripheral nerve blocks, epidural analgesia) can be continued postoperatively 1
• Adequate pain control is essential as pain itself may trigger stress responses 1

Complications and Outcomes

MS patients undergoing total hip arthroplasty have higher perioperative risks:

• Increased surgical complications (OR = 1.18,95% CI 1.02-1.37) 5
• Increased medical complications (OR = 1.55,95% CI 1.34-1.81) 5
• 8.24% longer hospital length of stay 5
• Higher likelihood of discharge to care facility (OR = 2.09,95% CI 1.82-2.40) 5

These findings likely apply to other major surgical procedures and should inform preoperative counseling 5.

Prophylactic Corticosteroids: Controversial

While some practitioners advocate for perioperative corticosteroid prophylaxis to prevent relapse 3, the most recent evidence does not support routine prophylaxis given the lack of increased relapse risk 4. Consider prophylactic corticosteroids only in select high-risk patients: those with recent relapse history, active disease, or undergoing major surgery with significant physiologic stress 3.

Special Considerations

Multidisciplinary Coordination:

• Involve neurology in perioperative planning for complex cases 1
• Coordinate with physical therapy for postoperative mobilization 5
• Plan for potential need for rehabilitation or extended care facility 5

Patient Counseling:

• Inform patients that surgery itself does not increase relapse risk 4
• Discuss realistic expectations for recovery given baseline functional status 5
• Counsel about higher risk of complications and longer recovery compared to non-MS patients 5