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Lumbosacral plexus compression by fetus: an unusual cause of radiculopathy during teenage pregnancy
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ELSEVIER
European Journal ot Obstetrics & Gynecology and Reproductive Rrology 73 ( 19971 203-204
.,-.--.
Case report
Lumbosacral
plexus compression by fetus: an unusual cause of radiculopathy during teenage pregnancy
Received 26 Novrember 1996: revised 7 January 1997: accepted 29 January 1997
Abstract A case is reported of a lumbosacral plexus compression by the fetus in a young 34-weeks pregnant woman, who had low-back pain and progressive muscular weakness of the leg. Neurological examination showed a grade IV motor weakness of the iliopsoas, quadriceps femoris and biceps femoris muscles. Mechanical stretch manoeuvers were negative. Electromyography revealed denervation activity in L4 and L5 muscles. Lumbosacral plexus radiculopathy was diagnosed. Although fetal compression appears to be an uncommon cause of 0 1997 lumbosacral radiculopathy during teenage pregnancy, both neurosurgeons and obstetricians should be aware of the possibility. Elsevier Science Ireland Ltd. Keywords:
Radiculopathy:
Lumbosacral:
Pregnancy:
Teenager:
I,ow-back
pain
1. Introduction
2. Case report
Although low-back pain is a well known condition during pregnancy, lumbar disc disease is an uncommon problem. LaBan et al. [l] found 5 pregnant patients with herniated lumbar disc during a series of 48 760 consecutive deliveries. Clinically, symptoms of radiculopathy start in the first trimester of pregnancy. On the other hand. lumbosacral plexus radiculopathy as a form of compression neuropathy is extremely rare and it more often develops during the third part of pregnancy [2,3]. In this report, we present a case of a young primigravid patient who had the symptoms of lumbosacral plexus radiculopathy that started during the third trimester of pregnancy.
A. 17-year-old primigravida woman started to suffer from acute low-back pain at 34 weeks of gestation. She complained of progressive weakness of the left leg. The course of the pregnancy had been uneventful until the abrupt onset. It was learnt that she had been evaluated previously by another obstetrician and caesarean section had been suggested because of her complaint of back pain. Routine biochemical studies showed no abnormality. Neurological examination revealed a grade IV motor weakness of the iliopsoas, quadriceps femoris and biceps femoris muscles. Stretch test of femoral nerve and Lasegue’s manoeuvres were negative. At term after an uncomplicated delivery a healthy girl was born vaginally. Neurological re-examination on the sixth day of the puerperium was identical. The spine X-ray was normal. Electromyography showed denervation activity in the adductor, iliopsoas and rectus femoris muscles. No denervation activity was found in the paravertebral muscles. Computerized tomography (CT) revealed a bulg-
*Corresponding author. Cumhuriyet Mahallesi. Cumhuriyet Caddesi. 2. Sokak No: I /6, TR-09020 Aydin, Turkey. Tel.: +90 256 2130740: Fax: +90 256 2120146.
0301-21 15/97/$17.00 0 1997 Elsevter Science h-eland Ltd. All rights reserved PII so301-21 lst97~02730-9
ing disc at L5-Sl level without a disc herniation. Lumbosacral plexus radiculopathy was diagnosed. She was mobilized and physiotherapy was initiated. On neurological re-examination four months later the muscle strength in her left leg was completely normal again and she had no complaints.
3. Discussion Pregnancy causes a considerable physical weight gain to the pregnant woman, and overload on the back and pelvis increases the risk of backache. There is an increase in lumbar lordosis and sacral angulation in pregnant women. This causes an increase in shearing stress across the lower lumbar discs and subsequent degenerative changes. Therefore, women are more prone to lumbar disc disease [4-s]. Symptoms begin with pain in the lumbar region with or without radiation into one or both legs during the third trimester of pregnancy. Electrophysiological and diagnostic imaging studies are indicated for the diagnosis of disc disease in problematic cases in which diagnosis and management is in question. In the present report, the symptoms of lumbosacral radiculopathy developed in a young woman at the 34th week of her gestation. Lumbosacral plexus radiculopathy in the adolescent age group is an unusual problem [9]. Moreover. pregnancy during adolescence has been shown to be associated with an increase in obstetric complications IlO]. In our country, unfortunately, many girls marry at the onset of puberty and considerable sociocultural pressure exists on the young women to bear children immediately to prove their fertility. Women with lumbosacral plexus radiculopathy during pregnancy are often told by some obstetricians that they need a caesarean section. as in this case. On the other hand, unfortunately, some neurosurgeons can also think that these patients require a neurosurgical intervention immediately after delivery. It was shown that the back pain was probably caused by a rise in relaxin concentration which resulted in collagen laxity and pelvic insufficiency during the third part of pregnancy [ 11,121. However, it is expected that such symptoms start during that period, as a result of pressure on the lumbosacral plexus by fetal parts.
For this reason. all pregnant patients with low-back pain should be referred to a neurosurgeon who is experienced in diagnosing and treating such patients. In conclusion. lumbosacral plexus radiculopathy at the end of pregnancy does not influence delivery and a favourable prognosis is always expected. Neither caesarean section nor lumbar discectomy is indicated. Considering the fact that complete recovery occurred after a physical therapy program in the case described above, an increased knowledge and understanding of the nature of the disorder among gynaecologists as well as among neurosurgeons would lower the need for surgical interventions.
References LaBan MM.
Perrin JCS. Latimel- FR. Prtipnancy and the herniatut
lumbar disc. Arch Phys Med Rehabil 1983: 64: 319-321. Delarue MWCi,Vlrs the third trimear
JSH, Hasaart THM.
Lumbosuxl
plexopnthy in
of pregnancy: a report of three c;w~. Eur J Obbtet
Gynecol Reprod Rio1 1994: S: h7-OX. Vxgo
MM.
Robinson LR,
lemoral newapathy.
Nicholas
JN.
Rulin
MC.
Postpartum
relw of an earlier era’! Arch Phy\ Med Rehabil
I090: 7 I : 5’)I --iY6 Walde
J. Obstetrical
and gynaecologul
hack and prlbic
pain\.
especially those contracted durmg pregnancy. Acta Ohktet Gynecol Sand
I l-53.
1963: JI:
O’Connell
JEA.
Lumbar
disc protruwns
in p~qnancy.
J Neural
Neurosurg P%ychiatrq 1960; 23: 138-141. Kelsey JL. Greenberg RA, Hardy RJ. Johnson MP. Pregnancy and the syndrome demiological iistgwd
of
herniated
lumbar
intervertebral
disc: an epi-
\tudq. Yale J Rio1 Med 1975: 3X: XII -36X.
HC. Andersaon GBJ, Wennergren
M. The impact of lo\\
back and pelvic pain in pregnancy on the pl-egnancy outcome. Acra Ohstet Gqnecol Stand
1991; 70: 21-24.
Mantle MJ, Greenwood
RM.
Cwq
HLF.
Backache in pqmmcy.
Rheumatol Rehabil IY77: 16: 95- 101. Turgut M. Hen11 K, Bcrtan V. Sa$w~ hcrniatitrn 111chlltlren and adolexents.
S. Lumbar Intervertcht-al disk Ncuro-Orthopedics
lY97 (in
prc\\1. Mahfow
AAK.
El-Said MM,
Al-Enan
RAG,
Hatmd AM. Teenage
pregnancy: are teenagers a htgh risk group? F.ur J Obstct Gynrcul Reprod Biol 1995: 59: 17-20. MacLennan
AH. Nicolson R, Green RC, Bath M. Serum Irelaxin in
pregnancy. Lancer IYX6; 2: 24 I-243. Kroc
RL.
Stelnerl
KG,
Beach
VL.
The
effccth
of
estqcns,
progehtagens, and relaxin in pregnant and non-pregnant laboratory rodenth. Ann Ucw Yorh Acad Sci 1959: 75: Y42-980.
ELSEVIER
European Journal ot Obstetrics & Gynecology and Reproductive Rrology 73 ( 19971 203-204
.,-.--.
Case report
Lumbosacral
plexus compression by fetus: an unusual cause of radiculopathy during teenage pregnancy
Received 26 Novrember 1996: revised 7 January 1997: accepted 29 January 1997
Abstract A case is reported of a lumbosacral plexus compression by the fetus in a young 34-weeks pregnant woman, who had low-back pain and progressive muscular weakness of the leg. Neurological examination showed a grade IV motor weakness of the iliopsoas, quadriceps femoris and biceps femoris muscles. Mechanical stretch manoeuvers were negative. Electromyography revealed denervation activity in L4 and L5 muscles. Lumbosacral plexus radiculopathy was diagnosed. Although fetal compression appears to be an uncommon cause of 0 1997 lumbosacral radiculopathy during teenage pregnancy, both neurosurgeons and obstetricians should be aware of the possibility. Elsevier Science Ireland Ltd. Keywords:
Radiculopathy:
Lumbosacral:
Pregnancy:
Teenager:
I,ow-back
pain
1. Introduction
2. Case report
Although low-back pain is a well known condition during pregnancy, lumbar disc disease is an uncommon problem. LaBan et al. [l] found 5 pregnant patients with herniated lumbar disc during a series of 48 760 consecutive deliveries. Clinically, symptoms of radiculopathy start in the first trimester of pregnancy. On the other hand. lumbosacral plexus radiculopathy as a form of compression neuropathy is extremely rare and it more often develops during the third part of pregnancy [2,3]. In this report, we present a case of a young primigravid patient who had the symptoms of lumbosacral plexus radiculopathy that started during the third trimester of pregnancy.
A. 17-year-old primigravida woman started to suffer from acute low-back pain at 34 weeks of gestation. She complained of progressive weakness of the left leg. The course of the pregnancy had been uneventful until the abrupt onset. It was learnt that she had been evaluated previously by another obstetrician and caesarean section had been suggested because of her complaint of back pain. Routine biochemical studies showed no abnormality. Neurological examination revealed a grade IV motor weakness of the iliopsoas, quadriceps femoris and biceps femoris muscles. Stretch test of femoral nerve and Lasegue’s manoeuvres were negative. At term after an uncomplicated delivery a healthy girl was born vaginally. Neurological re-examination on the sixth day of the puerperium was identical. The spine X-ray was normal. Electromyography showed denervation activity in the adductor, iliopsoas and rectus femoris muscles. No denervation activity was found in the paravertebral muscles. Computerized tomography (CT) revealed a bulg-
*Corresponding author. Cumhuriyet Mahallesi. Cumhuriyet Caddesi. 2. Sokak No: I /6, TR-09020 Aydin, Turkey. Tel.: +90 256 2130740: Fax: +90 256 2120146.
0301-21 15/97/$17.00 0 1997 Elsevter Science h-eland Ltd. All rights reserved PII so301-21 lst97~02730-9
ing disc at L5-Sl level without a disc herniation. Lumbosacral plexus radiculopathy was diagnosed. She was mobilized and physiotherapy was initiated. On neurological re-examination four months later the muscle strength in her left leg was completely normal again and she had no complaints.
3. Discussion Pregnancy causes a considerable physical weight gain to the pregnant woman, and overload on the back and pelvis increases the risk of backache. There is an increase in lumbar lordosis and sacral angulation in pregnant women. This causes an increase in shearing stress across the lower lumbar discs and subsequent degenerative changes. Therefore, women are more prone to lumbar disc disease [4-s]. Symptoms begin with pain in the lumbar region with or without radiation into one or both legs during the third trimester of pregnancy. Electrophysiological and diagnostic imaging studies are indicated for the diagnosis of disc disease in problematic cases in which diagnosis and management is in question. In the present report, the symptoms of lumbosacral radiculopathy developed in a young woman at the 34th week of her gestation. Lumbosacral plexus radiculopathy in the adolescent age group is an unusual problem [9]. Moreover. pregnancy during adolescence has been shown to be associated with an increase in obstetric complications IlO]. In our country, unfortunately, many girls marry at the onset of puberty and considerable sociocultural pressure exists on the young women to bear children immediately to prove their fertility. Women with lumbosacral plexus radiculopathy during pregnancy are often told by some obstetricians that they need a caesarean section. as in this case. On the other hand, unfortunately, some neurosurgeons can also think that these patients require a neurosurgical intervention immediately after delivery. It was shown that the back pain was probably caused by a rise in relaxin concentration which resulted in collagen laxity and pelvic insufficiency during the third part of pregnancy [ 11,121. However, it is expected that such symptoms start during that period, as a result of pressure on the lumbosacral plexus by fetal parts.
For this reason. all pregnant patients with low-back pain should be referred to a neurosurgeon who is experienced in diagnosing and treating such patients. In conclusion. lumbosacral plexus radiculopathy at the end of pregnancy does not influence delivery and a favourable prognosis is always expected. Neither caesarean section nor lumbar discectomy is indicated. Considering the fact that complete recovery occurred after a physical therapy program in the case described above, an increased knowledge and understanding of the nature of the disorder among gynaecologists as well as among neurosurgeons would lower the need for surgical interventions.
References LaBan MM.
Perrin JCS. Latimel- FR. Prtipnancy and the herniatut
lumbar disc. Arch Phys Med Rehabil 1983: 64: 319-321. Delarue MWCi,Vlrs the third trimear
JSH, Hasaart THM.
Lumbosuxl
plexopnthy in
of pregnancy: a report of three c;w~. Eur J Obbtet
Gynecol Reprod Rio1 1994: S: h7-OX. Vxgo
MM.
Robinson LR,
lemoral newapathy.
Nicholas
JN.
Rulin
MC.
Postpartum
relw of an earlier era’! Arch Phy\ Med Rehabil
I090: 7 I : 5’)I --iY6 Walde
J. Obstetrical
and gynaecologul
hack and prlbic
pain\.
especially those contracted durmg pregnancy. Acta Ohktet Gynecol Sand
I l-53.
1963: JI:
O’Connell
JEA.
Lumbar
disc protruwns
in p~qnancy.
J Neural
Neurosurg P%ychiatrq 1960; 23: 138-141. Kelsey JL. Greenberg RA, Hardy RJ. Johnson MP. Pregnancy and the syndrome demiological iistgwd
of
herniated
lumbar
intervertebral
disc: an epi-
\tudq. Yale J Rio1 Med 1975: 3X: XII -36X.
HC. Andersaon GBJ, Wennergren
M. The impact of lo\\
back and pelvic pain in pregnancy on the pl-egnancy outcome. Acra Ohstet Gqnecol Stand
1991; 70: 21-24.
Mantle MJ, Greenwood
RM.
Cwq
HLF.
Backache in pqmmcy.
Rheumatol Rehabil IY77: 16: 95- 101. Turgut M. Hen11 K, Bcrtan V. Sa$w~ hcrniatitrn 111chlltlren and adolexents.
S. Lumbar Intervertcht-al disk Ncuro-Orthopedics
lY97 (in
prc\\1. Mahfow
AAK.
El-Said MM,
Al-Enan
RAG,
Hatmd AM. Teenage
pregnancy: are teenagers a htgh risk group? F.ur J Obstct Gynrcul Reprod Biol 1995: 59: 17-20. MacLennan
AH. Nicolson R, Green RC, Bath M. Serum Irelaxin in
pregnancy. Lancer IYX6; 2: 24 I-243. Kroc
RL.
Stelnerl
KG,
Beach
VL.
The
effccth
of
estqcns,
progehtagens, and relaxin in pregnant and non-pregnant laboratory rodenth. Ann Ucw Yorh Acad Sci 1959: 75: Y42-980.