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16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

Management of Severe Radiculopathy in a Pregnant Patient

Applying a multidisciplinary approach to a complex case.
Pages 37-40

Low back pain affects approximately 50% of all pregnant women. There are numerous etiologies for back pain, such as biomechanical effects of gravid uterus, positional stressors, and hormonal effects of relaxin resulting in pain due to laxity of pubic symphysis or sacroiliac joint. The prevalence of disc pathology does not increase during gestation, but disc prolapse is one of the commonest reasons for spinal causes of pain, affecting 1 in 10,000 pregnant women.1 The pain management for acute disc prolapse may be challenging in pregnant patients considering the side effects of medications on the fetus, surgical morbidity, and effect of radiation during interventional pain management. Each decision taken in the management of pain needs to be weighed as a risk:benefit ratio to both mother and fetus. Mechanical back pain usually responds to conservative management, however intractable radicular pain may require additional diagnostic and treatment strategies. Here, the authors share a case of a 34-year-old female who presented in her second trimester with severe low back pain with unilateral radiculopathy.

The Patient

A 34-year-old female, gravida 4 and para 3, presented at 20.5 weeks’ period of gestation with severe low back pain. Her complaints were mid-lower back disabling pain radiating to left buttock, posterolateral thigh, leg and down to the left foot. She reported the pain at 10/10 in intensity, affecting her daily activities to the point that she had to use a walker to ambulate and eventually became bed-ridden. She denied any urinary or bowel incontinence. Her back pain started at the beginning of the second trimester and had been progressively increasing since that time.

Medical history was significant for a similar presentation one year prior. MRI of the lumbar spine at that time revealed L5/S1 circumferential disc bulge effacing ventral epidural fat and partially narrowing the inferior neural foramina. She had received left piriformis injection followed by left L5-S1 transformational epidural steroid injection (ESI) without alleviation of symptoms. She then underwent L5-S1 microdiscectomy, resulting in partial relief of symptoms.

Upon physical examination, pertinent findings included 4/5 motor strength in foot dorsiflexion and plantar flexion secondary to pain. A sensory exam revealed hypoesthesia in the left leg and foot. There was tenderness to palpation in the left lumbar and the sacral area. The straight leg raise test was positive at 20 degrees on the left leg.

(Source: 123RF)

Diagnosis and Management Approaches

MRI of the lumbar spine revealed left paracentral and lateral recess disc protrusion at L5-S1 level with impingement of left S1 nerve root (see Figure 1). There was no mass effect on central canal with adequate cerebrospinal fluid (CSF) signal. MRI provides a specific and non-invasive modality for imaging in pregnant women without exposure of the fetus to ionizing radiation. Electromyography (EMG) was also performed and suggestive of left S1 radiculopathy.

Figure 1. MRI of patient’s lumbar spine revealed left paracentral and lateral recess disc protrusion at L5-S1 level with impingement of left S1 nerve root.

During this admission, the patient was initially treated with scheduled acetaminophen, 500 mg every 8 hours. It did not provide her with adequate pain relief. Oxycodone was added after discussing the risk of neonatal abstinence syndrome (NAS) with the patient. NAS has been reported in 5 to 20% of the neonates exposed to opioids in utero.2 Oxycodone was added in the dose of 5 mg every 4 hours; acetaminophen was also increased to 500 mg every 6 hours. Two days later, Oxycodone was increased to 10 mg every 4 hours, but the patient reported minimal relief of symptoms with this medical management.

Analgesic use poses a challenge in pregnant patients due to the possibility of harm to the developing fetus. Based on human and animal studies, FDA has placed such drugs into five categories according to risk in pregnancy (see Table I).

Physical Therapy

A physical therapist taught the patient stretching and pelvic stabilizing exercises; she was also advised to use a pregnancy belt while walking and performing daily activities. She was unable to complete physical therapy, however, due to the severe pain. Therapeutic aquatic exercises done under a guarded program could have been beneficial as axial load on the spine is decreased after water immersion, however, the patient did not know how to swim.

Neurosurgery Consultation

Neurosurgery was consulted in view of neurologic deficits in the patient who, as noted, had recurrent disc herniation. Consultation suggested that disc herniation was likely due to axial loading and strain from pregnancy since the onset of pain roughly corresponded with the beginning of pregnancy. Another surgery for the patient’s current symptoms was not recommended since the risk of surgery far outweighed the benefit, due to the pregnancy.

Acupuncture

Acupuncture may be utilized for the relief of low back pain during pregnancy only after posture and proper body mechanics have been addressed. The practice may help by relaxing the muscles, releasing endogenous opioids and changing the perception of pain.3 Thus, daily acupuncture sessions provided by a therapist trained and certified in reproductive healthcare was provided. The patient reported good pain relief with acupuncture, but the relief lasted only a few hours after every session.

Psychotherapy

Cognitive behavioral therapy and biofeedback training may enable a patient to recognize and help control pain-related physiologic responses. This patient received a few daily sessions of psychotherapy from the clinic’s pain psychologist. Specifically, she received instruction on using a breathing technique (moving when exhaling) to keep pain from increasing during movement. She was also given cognitive behavioral therapy to adapt better to the current state of pain and was educated on the negative outcome of focusing on pain. She was given handouts to practice these techniques.

Interventional Pain Management

Interventional pain management options may be limited in pregnant women due to concern of harmful radiation effects on the developing fetus. After all the conservative management failed to give this particular patient adequate relief, the team performed a caudal ESI under the ultrasound guidance. The caudal approach was considered appropriate due to her prior surgery. Ultrasound (Sonosite M Turbo, Curvilinear probe) was used to visualize needle placement instead of fluoroscopy to avoid radiation. Refer to Figures 2 and 3. The injection included 8 cc of 0.125 % of bupivacaine and 40 mg of methylprednisolone. The patient reported 70% pain relief after the procedure and was able to participate in physical therapy the next day. Per physical therapy evaluation, she was safely discharged home.

Figure 2. ESI of the case patient: epidural space is localized below the sacrococcygeal membrane when visualized by the caudal approach.

Figure 3. Real-time placement of needle and spread of the medication in the epidural space in case patient.

Outcome

The patient was discharged with acetaminophen 500 mg every 6 hours, scheduled for breakthrough pain and oxycodone 5 mg every 6 hours PRN. She followed up in the pain clinic after 2 months, at 28 weeks and 4 days’ period of gestation. Her pain was controlled during this visit with PRN Tylenol and she was able to perform her daily activities.

Discussion

Acute disc prolapse is a rare cause of low back pain in pregnancy but may be very distressing for a patient and severe enough to either render a patient bedridden, as in the presented case, or wheelchair-bound as described in a case by Croissant, et al.4 A delay in diagnosis can lead to permanent neurological deficit.5 During evaluation, red flags such as cauda equina syndrome or progressive increase in motor and sensory deficit should be ruled out. MRI is a useful diagnostic tool for a pregnant patient presenting with spinal pain to confirm the level and extent of disc protrusion.1

In the absence of cauda equina syndrome or acute motor and sensory deficit, initial treatment should always be conservative and aimed at symptomatic management. Pain control is important to prevent the development of chronic pain and for improvement in mobility, as well as for the prevention of thromboembolism. Conservative management may include analgesics, physical therapy, acupuncture, and use of a pelvic belt. Use of an orthopedic bed has shown to be beneficial for back support and, hence, decreasing pain.4

Previous studies have recommended a multidisciplinary approach for back pain in pregnancy.4,6 In this case, an obstetric team, anesthesia and pain specialists, neurosurgeon, an acupuncture therapist, a pain psychologist, and a physiotherapist were involved in the patient’s care. She was scheduled on round-the-clock analgesics, which helped a little. Specific stabilizing exercises have been shown to decrease the pain and strengthen the pelvic muscles7 but, in this case, the patient was in too much severe pain to carry out the exercises and physiotherapy. Surgery has been recommended by few authors in case of acute disc herniation with good outcomes,8,9 however, in this case, surgery was deferred as risks outweighed potential benefits. Acupuncture at specific points has been reported to provide a significant reduction in pain although the effects were short-term as seen in this case;11,12 the patient continued to stay bed-ridden. Immobility secondary to pain is a moderate risk factor for thromboembolism and in the presence of two other risk factors, an indication to start anticoagulants.13

Given the short-term effect and minimal response seen to the conservative approaches, the authors decided to proceed with the ESI. The caudal epidural approach was considered in view of the patient’s history of previous back surgery. The injection was performed under ultrasound (USG) guidance to avoid the risk of exposure to radiation to the fetus. USG has been successfully used in the past for interventions in pain management and has been recommended to use in special situations like pregnancy.14 The strongest evidence for the success of epidural injection is for back pain related to the disc pathology.15 Rathmell, et al, suggested that even though the risk of single-dose epidural steroid is low, the epidural injection should be reserved for the pregnant patient in whom symptoms are suggestive of lumbar root compression.16

Pincus, et al, reported that psychological factors, if left untreated, may cause progression to chronic pain and interventions should also be targeted to address these factors.17 In this case, a pain psychologist taught the patient various techniques to help her better adapt to her current state and minimize the burden of pain. After the ESI, the patient’s pain was controlled and, subsequently, she was able to work with a physical therapist and learn specific stabilizing exercises to strengthen the pelvic muscles.

Conclusion

Back pain in pregnancy may be multifactorial and its management may be challenging due to controversies regarding the safety of analgesic use, risk of radiation exposure to the fetus with interventional procedures, and morbidity with surgical options. In absence of any progressive neurological deficits and cauda equina syndrome, conservative management is preferred, individualized to each patient. A multidisciplinary approach is vital not only for optimal pain management but also for functional and psychological recovery.

Last updated on: April 12, 2019
Continue Reading:
Axial Neck Pain, Radiculopathy, and Myelopathy: Recognition and Treatment
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