Spinal Anaesthesia in Compressive Myelopathy
Spinal anesthesia is not contraindicated in patients with compressive myelopathy, but requires careful risk-benefit assessment and multidisciplinary planning to minimize the risk of neurological deterioration.
Key Safety Considerations
Risk Assessment Framework
The primary concern with spinal anesthesia in compressive myelopathy is the theoretical risk of worsening spinal cord compression or ischemia during needle insertion, local anesthetic injection, or positioning. However, no high-quality evidence exists demonstrating that spinal anesthesia is absolutely contraindicated in this population 1.
- Anesthesia is not contraindicated even in conditions with spinal cord involvement, as demonstrated in systemic mastocytosis guidelines where surgery and anesthesia are permitted despite neurological risks 1
- The decision should prioritize avoiding temperature extremes, unnecessary trauma during positioning, and hemodynamic instability that could compromise spinal cord perfusion 1
Critical Pre-Anesthetic Evaluation
Before proceeding with spinal anesthesia in compressive myelopathy, document:
- Severity of cord compression on MRI: Patients with severe multi-level compression and narrow spinal canal diameter (≤14.5 mm) are at higher risk of neurological deterioration 2
- Baseline neurological status: Use modified Japanese Orthopaedic Association (mJOA) score to quantify preoperative function 3, 4
- Level of compression: Cervical myelopathy poses different risks than thoracic or lumbar stenosis 1
- Presence of cord signal changes: T2 hyperintensity on MRI indicates myelomalacia and worse prognosis 1
Safer Anesthetic Alternatives
General anesthesia may be preferable to spinal anesthesia in patients with significant compressive myelopathy for several reasons:
- Avoids direct needle trauma near compressed cord segments 1
- Allows better hemodynamic control to maintain spinal cord perfusion pressure 1
- Permits intraoperative neurophysiological monitoring if needed 1
- Reduces risk of positioning-related cord injury during prolonged procedures 1
If spinal anesthesia is chosen, use the lowest effective dose of local anesthetic and avoid hypotension that could compromise cord perfusion 1.
Multidisciplinary Planning Requirements
Mandatory coordination between surgical, anesthesia, and perioperative teams is essential 1:
- Review prior anesthetic records for any complications 1
- Identify specific triggers that could worsen cord compression (positioning, blood pressure changes) 1
- Establish clear protocols for managing acute neurological deterioration 1
- Consider prophylactic corticosteroids to reduce cord edema risk 1
Intraoperative Monitoring
For patients with moderate-to-severe myelopathy (mJOA <15), consider:
- Continuous blood pressure monitoring to maintain mean arterial pressure >85 mmHg for cord perfusion 1
- Avoid hypothermia which can worsen cord ischemia 1
- Careful positioning to prevent hyperextension or hyperflexion of the spine 1
Common Pitfalls to Avoid
- Do not delay necessary surgery due to anesthesia concerns—progressive myelopathy has worse outcomes than early intervention 1, 4
- Do not assume all cord compression is symptomatic—asymptomatic radiographic compression alone does not require prophylactic intervention 5
- Do not rely solely on clinical examination—postoperative MRI may be needed to confirm adequate decompression if neurological decline occurs 6
- Do not ignore age as a prognostic factor—patients >65 years have worse recovery rates regardless of anesthetic technique 1
Special Populations
Patients with multiple sclerosis and coexisting cervical cord compression can safely undergo surgery and anesthesia with minimal morbidity when carefully selected 7. The key distinguishing features are neck pain and radiculopathy, which suggest mechanical compression rather than MS exacerbation 7.
Postoperative Vigilance
Monitor for: