Multiple sclerosis

Learning objectives

Knowing the challenges in the perioperative management of patients with multiple sclerosis

Multiple sclerosis is a chronic disabling demyelinating inflammatory disease of the central nervous system
It involves demyelination in scattered areas of the central nervous system
This leads to the slowing of conduction along the affected neural pathway
More often in women, it usually presents its first symptoms between the ages of 20 and 40
Cause is unknown, the most widely accepted theory is of an inflammatory immune-mediated disorder
There are different types:
- Primary-progressive MS
- Secondary-progressive MS
- Relapsing-remitting MS
Diagnosis is based on McDonald’s criteria
Management is multidirectional
- Therapy of exacerbations:
  - Corticosteroids
- Prevention of exacerbations:
  - Immunomodulatory therapy: interferon beta, glatiramer, Alemtuzumab
- Therapy of chronic symptoms:
  - E.g., spasticity: baclofen
  - E.g., pain: anticonvulsants
  - E.g., urinary incontinence: oxybutynin

Symptoms vary depending on the nerve fibers affected:

Respiratory	FRC ↓, diaphragmatic paralysis, central control of ventilation is altered, risk of chronic aspiration (due to cranial nerve involvement with impaired control of pharyngeal and laryngeal muscles) Increased incidence of obstructive sleep apnea
Autonomic nervous system	Hemodynamic instability Syncope, impotence, bladder and bowel dysfunction, vasomotor instability, orthostasis
Neurological	Sensory deficits: numbness, tingling, itching of the extremities or trunk. Impairment of facial sensation, trigeminal neuralgia, hemifacial spasms, facial myokymia Cerebellar involvement: tremor, scanning speech, coordination defects, nystagmus, unsteady gait Motor deficits: paraparesis, paraplegia, spasticity, increased deep tendon reflexes Cognitive impairment Increased incidence of epilepsy Fatigue Depression, bipolar disease Pain
Visual	Optic neuritis: (unilateral) scotoma, painful eye movements, double or blurred vision
Urological	Bladder dysfunction

Perioperative stress or anesthesia are often implicated as causes of exacerbation of the disease
Infection, emotional lability, and hyperpyrexia may explain the increased frequency of multiple sclerosis exacerbation postoperatively