Failed epidural analgesia in a childhood cancer survivor who received intrathecal chemotherapy: a case report

Abstract

The incidences of childhood leukemia and non-Hodgkin lymphoma (NHL) in the United States have steadily risen in the past two decades. Many patients with hematopoietic and lymphoid malignancies will receive both systemic and intrathecal chemotherapy to treat primary leptomeningeal cancer or secondary metastatic disease. Female survivors of childhood cancers may eventually desire parenthood, and the impact of intrathecal chemotherapy on neuraxial analgesia and anesthesia is unclear. We report a case of a primigravid parturient who, as a survivor of adolescent NHL, was treated with systemic and intrathecal methotrexate and cytarabine. Upon presenting for induction of labor in the setting of preeclampsia, the patient requested labor epidural analgesia. A dural puncture epidural (DPE) technique was performed by an experienced anesthesiologist, and though the procedure was straightforward, it resulted in minimal analgesic effect. Subsequently, a combined spinal epidural (CSE) analgesia was performed, with approximately two hours of analgesia followed by no epidural analgesia. An intentional dural puncture (17G) with an intrathecal catheter (20G) was discussed and accepted by the patient, and despite CSF confirmation, the technique was aborted due to significant catheter resistance. Our case of failed analgesia with multiple neuraxial techniques in a parturient who had previously received intrathecal chemotherapy raises a management dilemma. Future investigations into the impact of type, dose, duration, and cycles of intrathecal chemotherapy; the possible value of antepartum imaging; and the success of epidural or spinal analgesia and anesthesia are warranted.