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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
Page 1 of 2

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

Last updated on: March 4, 2019
Continue Reading:
Axial Neck Pain, Radiculopathy, and Myelopathy: Recognition and Treatment
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