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Lumbar discectomy in pregnancy
International Journal of Gynecology and Obstetrics (2006) 92, 167 — 169
www.elsevier.com/locate/ijgo
CASE REPORT
Lumbar discectomy in pregnancy M.A. Abou-Shameh *, D. Dosani, S. Gopal, A.G. McLaren Department of Trauma and Orthopaedics, York District Hospital, York, U.K. Received 14 August 2005; received in revised form 28 September 2005; accepted 30 September 2005
KEYWORDS Back pain; Pregnancy; Lumbar discectomy
More than 50% of pregnant women experience some degree of lower back discomfort, which can be treated conservatively in most cases. In approximately 1 in 10,000 pregnancies, however, a lumbar disc prolapse gives rise to intractable pain, not only in the back but also all along sciatic nerve distribution [1]. As only a handful of such reports exist in the literature (Table 1), there follows a report of successful discectomy in a pregnant woman. A married 34-year-old, 18-week-pregnant white woman, gravida 2, para 1, presented to the antenatal clinic of the York District Hospital, York, United Kingdom, with a 4-week history of incapacitating back and right-sided sciatica. She was unable to cope at home. On examination her straight leg raise was restricted to 458, with a positive sciatic nerve stretch test. A neurological
4 Corresponding author. 6 Tuke Grove, Wakefield, WF1 4DJ, UK. Tel.: +44 7917411610; fax: +44 1924332996. E-mail address: [email protected] (M.A. Abou-Shameh).
examination revealed hypoesthesia in the L5 dermatome but no motor weakness. Deep tendon reflexes were normal. A flowchart of the followed procedure is shown in Fig. 1. Over the previous 5 years the patient had been treated on and off by her family physician for back discomfort, with no other significant medical history. As her symptoms were not improving with bed rest and routine analgesia, she was referred to a spinal surgeon on the fourth postadmission day. Magnetic resonance imaging (MRI) showed a large right-sided, paracentral disc prolapse at the level of L4/5 (Figs. 2 and 3) with effacement of the adjacent nerve root. The patient underwent a right-sided L4/5 discectomy on the eighth postadmission day under general anesthesia. The knee/ elbow position was used, with simple side supports and no other special precautions. Fetal heart monitoring was checked immediately before and immediately after surgery. The patient had an uneventful recovery, with complete resolution of her leg symptoms within 24 h. She was discharged 2 days postoperatively, and was delivered of a healthy infant at term. At her last surgical follow-up appointment, 4 months postoperatively, she had no sciatic pain. Lumbar disc herniation is uncommon during pregnancy. Once severe cauda equina compression has been ruled out, initial management includes
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2005.09.028
168 Table 1
M.A. Abou-Shameh et al. Summary of previously reported cases
Author and year reported
Pregnancy trimester at onset of symptoms
Age (year)
Finding
Treatment
Complication
LaBan, 1995 [5] LaBan, 1995 [5] LaBan, 1995 [5]
1st 2nd 2nd
29 31 32
L5—S1, HD L5—S1, HD L5—S1, HD
Laminectomy Laminectomy Laminectomy
LaBan, 1995 [6]
2nd
36
Laminectomy
[2] [2]
2nd 1st
29 34
S1, cauda equina block L5—S1, HD S1, HD
None None Foot drop, postsurgical improvement None
[2] Brown, 2001 [4]
3rd 2nd
28 41
Discectomy Laminectomy and discectomy Laminectomy Laminectomy
L5—S1, HD L5, cauda equina block
None None None Stress incontinence, constipation
HD, herniated disc; L, lumbar; S, sacral. The investigation method was magnetic resonance imaging in all cases.
bed rest, physiotherapy, muscle relaxants, and analgesia [2]. An epidural injection of steroids can also be considered for women in their second or third trimester of pregnancy. In cases where symptoms prove persistent, and where MRI reveals a lesion corresponding to the clinical situation, surgical intervention is indicated (Fig. 1). Magnetic resonance imaging has been shown to have no adverse effects on the progression of pregnancy or on the fetus [3].
The position of the patient is critical during surgery. Brown and Levi used a Relton-Hall laminectomy frame [4] and the patient in the present report was placed in the knee/elbow prone position, with simple side supports for security. The lateral position should be considered in the third trimester. Of 8 patients described in the previous literature, 7 experienced complete resolution of their symptoms but the remaining patient, whose initial
Clinical Diagnosis of Sciatica
Only Severe With neurological symptoms
Physiotherapy Analgesia Temporise
Settling
Not settling Deteriorating
MRI scan
Consider Discharge
Figure 1
Epidural injection
Surgery Failed
Flow chart showing sciatica management in pregnancy.
Lumbar discectomy in pregnancy
169 presentation included a cauda equina syndrome, was left with long-term sequelae (Table 1). Lumbar disc prolapse should be considered in pregnant women presenting with severe back or leg pain, and magnetic resonance imaging is the definitive diagnostic procedure. Most affected patients can be treated conservatively, but those with disabling pain, progressive neurological deficit, or cauda equina syndrome may require surgery. Along with the previous reports, this report suggests that severe symptomatic lumbar disc herniation during pregnancy can be safely treated by standard surgical techniques.
References Figure 2 Axial magnetic resonance image of the lumbosacral spine demonstrating a large right paracentral disc prolapse at L4/L5, causing effacement of the right L5 nerve root.
Figure 3 Sagittal T1-weighted magnetic resonance image of the lumbosacral spine demonstrating a large right paracentral disc prolapse at the L4/L5 level.
[1] LaBan MM, Perrin JC, Latimer FR. Pregnancy and herniated lumbar disc. Arch Phys Med Rehabil 1983;64:319 – 21. [2] Garmel S, Guzelian G, D’Alton J, D’Alton M. Lumbar disc disease in pregnancy. Obstet Gynecol 1997;89(5):821 – 3. [3] Evans JA, Savitzda DA, kanal E, Gillent J. Infertility and pregnancy outcome among magnetic resonance imaging workers. J Occup Med 1993;35:1191 – 5. [4] Brown M, Levi A. Lumbar surgery during pregnancy. Spine 2001;26:440 – 3. [5] LaBan MM, Rapp NS, Oeyen PV, Meerschaert JR. The lumbar herniated disc of pregnancy: A report of six cases identified by magnetic resonance imaging. Arch Phys Med Rehabil 1995;76:476 – 9. [6] LaBan MM, Viola S, Williams DA, Wang A. Magnetic resonance imaging of the lumbar herniated disc in pregnancy. Am J Phys Med Rehabil 1995;74:59 – 61.
www.elsevier.com/locate/ijgo
CASE REPORT
Lumbar discectomy in pregnancy M.A. Abou-Shameh *, D. Dosani, S. Gopal, A.G. McLaren Department of Trauma and Orthopaedics, York District Hospital, York, U.K. Received 14 August 2005; received in revised form 28 September 2005; accepted 30 September 2005
KEYWORDS Back pain; Pregnancy; Lumbar discectomy
More than 50% of pregnant women experience some degree of lower back discomfort, which can be treated conservatively in most cases. In approximately 1 in 10,000 pregnancies, however, a lumbar disc prolapse gives rise to intractable pain, not only in the back but also all along sciatic nerve distribution [1]. As only a handful of such reports exist in the literature (Table 1), there follows a report of successful discectomy in a pregnant woman. A married 34-year-old, 18-week-pregnant white woman, gravida 2, para 1, presented to the antenatal clinic of the York District Hospital, York, United Kingdom, with a 4-week history of incapacitating back and right-sided sciatica. She was unable to cope at home. On examination her straight leg raise was restricted to 458, with a positive sciatic nerve stretch test. A neurological
4 Corresponding author. 6 Tuke Grove, Wakefield, WF1 4DJ, UK. Tel.: +44 7917411610; fax: +44 1924332996. E-mail address: [email protected] (M.A. Abou-Shameh).
examination revealed hypoesthesia in the L5 dermatome but no motor weakness. Deep tendon reflexes were normal. A flowchart of the followed procedure is shown in Fig. 1. Over the previous 5 years the patient had been treated on and off by her family physician for back discomfort, with no other significant medical history. As her symptoms were not improving with bed rest and routine analgesia, she was referred to a spinal surgeon on the fourth postadmission day. Magnetic resonance imaging (MRI) showed a large right-sided, paracentral disc prolapse at the level of L4/5 (Figs. 2 and 3) with effacement of the adjacent nerve root. The patient underwent a right-sided L4/5 discectomy on the eighth postadmission day under general anesthesia. The knee/ elbow position was used, with simple side supports and no other special precautions. Fetal heart monitoring was checked immediately before and immediately after surgery. The patient had an uneventful recovery, with complete resolution of her leg symptoms within 24 h. She was discharged 2 days postoperatively, and was delivered of a healthy infant at term. At her last surgical follow-up appointment, 4 months postoperatively, she had no sciatic pain. Lumbar disc herniation is uncommon during pregnancy. Once severe cauda equina compression has been ruled out, initial management includes
0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2005.09.028
168 Table 1
M.A. Abou-Shameh et al. Summary of previously reported cases
Author and year reported
Pregnancy trimester at onset of symptoms
Age (year)
Finding
Treatment
Complication
LaBan, 1995 [5] LaBan, 1995 [5] LaBan, 1995 [5]
1st 2nd 2nd
29 31 32
L5—S1, HD L5—S1, HD L5—S1, HD
Laminectomy Laminectomy Laminectomy
LaBan, 1995 [6]
2nd
36
Laminectomy
[2] [2]
2nd 1st
29 34
S1, cauda equina block L5—S1, HD S1, HD
None None Foot drop, postsurgical improvement None
[2] Brown, 2001 [4]
3rd 2nd
28 41
Discectomy Laminectomy and discectomy Laminectomy Laminectomy
L5—S1, HD L5, cauda equina block
None None None Stress incontinence, constipation
HD, herniated disc; L, lumbar; S, sacral. The investigation method was magnetic resonance imaging in all cases.
bed rest, physiotherapy, muscle relaxants, and analgesia [2]. An epidural injection of steroids can also be considered for women in their second or third trimester of pregnancy. In cases where symptoms prove persistent, and where MRI reveals a lesion corresponding to the clinical situation, surgical intervention is indicated (Fig. 1). Magnetic resonance imaging has been shown to have no adverse effects on the progression of pregnancy or on the fetus [3].
The position of the patient is critical during surgery. Brown and Levi used a Relton-Hall laminectomy frame [4] and the patient in the present report was placed in the knee/elbow prone position, with simple side supports for security. The lateral position should be considered in the third trimester. Of 8 patients described in the previous literature, 7 experienced complete resolution of their symptoms but the remaining patient, whose initial
Clinical Diagnosis of Sciatica
Only Severe With neurological symptoms
Physiotherapy Analgesia Temporise
Settling
Not settling Deteriorating
MRI scan
Consider Discharge
Figure 1
Epidural injection
Surgery Failed
Flow chart showing sciatica management in pregnancy.
Lumbar discectomy in pregnancy
169 presentation included a cauda equina syndrome, was left with long-term sequelae (Table 1). Lumbar disc prolapse should be considered in pregnant women presenting with severe back or leg pain, and magnetic resonance imaging is the definitive diagnostic procedure. Most affected patients can be treated conservatively, but those with disabling pain, progressive neurological deficit, or cauda equina syndrome may require surgery. Along with the previous reports, this report suggests that severe symptomatic lumbar disc herniation during pregnancy can be safely treated by standard surgical techniques.
References Figure 2 Axial magnetic resonance image of the lumbosacral spine demonstrating a large right paracentral disc prolapse at L4/L5, causing effacement of the right L5 nerve root.
Figure 3 Sagittal T1-weighted magnetic resonance image of the lumbosacral spine demonstrating a large right paracentral disc prolapse at the L4/L5 level.
[1] LaBan MM, Perrin JC, Latimer FR. Pregnancy and herniated lumbar disc. Arch Phys Med Rehabil 1983;64:319 – 21. [2] Garmel S, Guzelian G, D’Alton J, D’Alton M. Lumbar disc disease in pregnancy. Obstet Gynecol 1997;89(5):821 – 3. [3] Evans JA, Savitzda DA, kanal E, Gillent J. Infertility and pregnancy outcome among magnetic resonance imaging workers. J Occup Med 1993;35:1191 – 5. [4] Brown M, Levi A. Lumbar surgery during pregnancy. Spine 2001;26:440 – 3. [5] LaBan MM, Rapp NS, Oeyen PV, Meerschaert JR. The lumbar herniated disc of pregnancy: A report of six cases identified by magnetic resonance imaging. Arch Phys Med Rehabil 1995;76:476 – 9. [6] LaBan MM, Viola S, Williams DA, Wang A. Magnetic resonance imaging of the lumbar herniated disc in pregnancy. Am J Phys Med Rehabil 1995;74:59 – 61.