Due to diagnostic, therapeutic, and rehabilitative advances, obstetric anesthesia providers are increasingly likely to encounter patients with disorders of the spinal cord. Sound knowledge of associated anatomic and physiologic abnormalities, coupled with an understanding of how the physiologic changes of pregnancy interact, are crucial to managing these increasingly complex patients. This chapter covers congenital and acquired spinal cord disorders, including acute and chronic spinal cord injury, spinal dysraphism, spinal cord tumors and vascular malformations, syringomyelia, the anterior spinal artery syndrome, infectious diseases and neurodegenerative conditions. Multidisciplinary management, with the team ideally being convened prior to conception, is crucial. For the most part, parturients with spinal cord disorders can attempt vaginal delivery. Operative delivery is usually reserved for obstetric reasons, for patients who would be unlikely to tolerate labor due to cardiopulmonary comorbidity, or for patients whose spinal cord pathology mandates delivery prior to, or synchronous with, definitive management. While spinal cord disorders do not necessarily preclude neuraxial anesthesia per se, providers are urged to obtain recent neuroimaging, and to document a preanesthetic neurological examination. The presence of surgical metalwork or implanted devices may pose challenges requiring an individualized approach.

Traumatic spinal cord injury requires urgent imaging and decision-making involving a team approach. Causes of nontraumatic spinal cord injury are protean and can be roughly divided into compressive and non-compressive disease states. In general, it is the scenario of compressive spinal injury that needs to be identified quickly for possible urgent surgical decompression, whereas non-compressive injury requires a systematic work-up, which is somewhat less urgent. MRI is the imaging modality of choice for essentially all acute spinal cord disorders presenting to the ED, and the physician is charged with expeditious performance of this testing whenever spinal cord compression is deemed a likely possibility.

Multiple sclerosis (MS) is a common disorder, characterized by inflammatory lesions of the CNS (brain and spinal cord), affecting approximately 0.15% of the population in the United States. The disease has a peak incidence in the second and third decades of life, typically presenting in this age group as relapsing–remitting disease (RRMS). Patients with RRMS present to the emergency department (ED) with acute exacerbations of their illness, as well as “pseudorelapses” relating to concomittent illness, often febrile. Good recovery from attacks is typically seen following the initial attacks. Attack frequency decreases with time, but many patients begin to accumulate permanent disability within the first decade after onset. In patients over 40 years of age, the disease presents commonly as a slow primary progressive illness (PPMS). Approximately 10–15% of patients have PPMS.