LAUSR

A 26-year-old primigravida with 26 weeks of gestation (POG) presented with neck pain radiating to bilateral upper limbs for 10 days. She developed progressive weakness of the upper limbs, followed by weakness of the lower limbs over 4 days. The upper and lower limb power was 3/5 and 0/5, respectively. Deep tendon reflexes were absent. Bowel and bladder sensations were lost with complete loss of sensations below C5. Magnetic resonance imaging revealed an extradural space-occupying lesion measuring 25 × 4.5 × 13.4 mm, from C5–C7, with anterior cord displacement and oedema from C4-C7 [Figure 1]. She gave a history of dengue 10 days before the onset of neurological symptoms with high-grade fever that lasted for 8 days. Platelet counts (PCs) had decreased to 90,000/mm3 on day 6 but had improved subsequently to 1.8 lakhs.mm−3. Coagulation remained normal throughout. Cervical spine exploration with decompression under general anaesthesia (GA) was planned. Obstetrician confirmed a viable foetus of 26 weeks with a foetal heart rate (FHR) of 158 min-1. Blood investigations revealed a haemoglobin level of 8.3 g%, a total leucocyte count of 6900 mm-3, and a PC of 1.8 lakhs.mm-3. Liver function tests, renal function tests, prothrombin time, international normalised ratio, and activated partial thromboplastin time were within normal limits. NS1 antigen was positive 10 days before neurological symptoms. On arrival at the operation theatre (OT), standard American Society of Anesthesiologists (ASA) monitors were attached and a wedge was placed for left lateral tilt. Difficult airway was anticipated. After 5 minutes of preoxygenation with 100% oxygen, modified rapid sequence induction (RSI) was performed. The trachea was intubated using a video laryngoscope and stylet. The lateral position was chosen to allow better placental circulation and FHR monitoring. A mean arterial pressure of 80–90 mmHg was maintained. A right cervical incision from C3–C7 was taken. Exploration revealed a thick extradural haematoma of approximately 10 cc from the C4–C7 vertebral body, which was evacuated [Figure 2]. No arteriovenous malformation was noted. The intraoperative blood loss was 800 ml. Haemodynamic stability was maintained throughout and the FHR was monitored intermittently via auscultation. She was electively ventilated for 12 hours, followed by extubation. The Glasgow coma scale score was 15/15, the upper limb power was 2/5, whereas the lower limb power was 0/5. In view of the absence of improvement of motor power, pregnancy was electively terminated via caesarean section (CS) under GA at 31 weeks of POG. The baby was observed in the neonatal intensive care unit in view of prematurity and low birth weight (1.4 kg). She was discharged from the hospital on POD32 with a motor power of 3/5 and 1/5, respectively.