Multiple Sclerosis 

 

 

 

Background

 

  • Heterogenous disorder with variable clinical & pathologic features

  • Inflammation, demyelination & denervation are the major pathologic mechanisms that cause the clinical manifestations

  • Cause unknown, most widely accepted theory is of an inflammatory immune-mediated disorder

 

 

Considerations 

 

  • Multisystem effects of demyelination:

    • Aspiration risk (bulbar dysfunction)

    • Respiratory failure/insufficiency (central hypoventilation & neuromuscular weakness)

    • Autonomic dysfunction with possible hemodynamic instability

  • Altered response to NMBs (neuromuscular blocking drugs):

    • Succinylcholine contraindicated due to hyperkalemia risk (denervation, misuse myopathy)

    • Sensitive to NdMRs (nondepolarizing muscle relaxants), but can also be resistant

  • Potential perioperative exacerbation of disease:

    • Neuraxial technique (spinal > epidural) but very controversial & some sources suggest regional/neuraxial acceptable 

    • Hyperthermia

  • Immunosuppressive medications (steroids, interferon, methotrexate)

 

 

Goals 

 

  • Minimize aspiration risk (consider prophylaxis, RSI)

  • Maximize respiratory function (avoid paralysis, full NMB reversal, secretions, pain management)

  • Maintain hemodynamic stability

  • Prevent postoperative exacerbations by avoiding triggers (hyperthermia, stress, +/- neuraxial)

  • Inform patient of potential perioperative aggravation of symptoms

 

 

Conflicts

 

  • Neuraxial technique vs. disease exacerbation:

    • Spinal traditionally considered contraindicated, but controversial

    • Low dose epidural most likely safe, have discussion with patient 

    • Peripheral nerve block is safe, as those nerves are not involved 

  • RSI vs. hemodynamic stability 

  • RSI vs. avoid succinylcholine

 

 

Pregnancy Considerations  

 

  • Neuraxial (both epidural/spinal) NOT contraindicated 

  • Discuss risk with patient that there may be post-operative/post-delivery relapse, regardless of anesthetic technique 

 

 

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