How to treat lumbar disc herniation in pregnancy?Eur Spine J. 2017;26:496-504. [PMID: 28429143 DOI: 10.1007/s00586-017-5040-8]

Evaluation of Spin in Systematic Reviews and Meta-Analyses of Minimally Invasive Surgical Techniques and Standard Microdiscectomies for Treating Lumbar Disc Herniation

STUDY DESIGN

Systematic review.

OBJECTIVES

Spin in scientific literature is defined as bias that overstates efficacy and/or underestimates harms of procedures undergoing review. While lumbar microdiscectomies (MD) are considered the gold standard for treating lumbar disc herniations (LDH), outcomes of novel procedures are being weighed against open MD. This study identifies the quantity and type of spin in systematic reviews and meta-analyses of LDH interventions.

METHODS

A search was conducted on the PubMed, Scopus, and SPORTDiscus databases for systematic reviews and meta-analyses evaluating the outcomes of MD against other LDH interventions. Each included study's abstract was assessed for the presence of the 15 most common types of spin, with full texts reviewed during cases of disagreement or for clarification. Full texts were used in the assessment of study quality per AMSTAR 2.

RESULTS

All 34 included studies were observed to have at least 1 form of spin, in either the abstract or full text. The most common type of spin identified was type 5 ("The conclusion claims the beneficial effect of the experimental treatment despite a high risk of bias in primary studies"), which was observed in ten studies (10/34, 29.4%). There was a statistically significant association between studies not registered with PROSPERO and the failure to satisfy AMSTAR type 2 (P < .0001).

CONCLUSION

Misleading reporting is the most common category of spin in literature related to LDH. Spin overwhelmingly tends to go in the positive direction, with results inappropriately favoring the efficacy or safety of an experimental intervention.

Management of cauda equina syndrome during pregnancy and postpartum

Cauda equina syndrome (CES) is a rare condition that occurs from multiple nerve root compression. It is considered a surgical emergency because it can lead to permanent neurological damage. There is limited literature regarding management and prognosis of CES for pregnant patients, leaving providers with many questions when encountering patients with this condition. We describe the case of a patient who developed CES during pregnancy. She presented at 30 weeks gestation and successfully underwent surgical decompression in prone position. She later delivered via elective caesarean at term. This case highlights management considerations for pregnant patients with CES, including positioning during surgery and use of regional anaesthesia.

Retraction of lumbar disc herniation achieved by noninvasive techniques: A case report

BACKGROUND

Lumbar disc herniation (LDH) has emerged as one of the most common causes of low back pain. The routine treatment approach involves chemonucleolysis therapy, discectomy by percutaneous endoscopy, and percutaneous laser disc decompression. Unfortunately, all of these methods carry inherent risk of causing harm to the patient and, as such, there is an unmet but urgent need for an effective and safe noninvasive treatment for LDH. The purpose of this report is to describe a non-invasive method for re-absorption of LDH.

CASE SUMMARY

A 34-year-old woman was admitted with a complaint of waist pain that she reported as having become acutely aggravated over the past 3 d and accompanied by discomfort in the right lower limb. Her self-reported medical history included persistent postpartum low back pain from 7 years prior. Physical exam showed positivity for neck flexion test (Lindner sign) and supine abdomen test; the straight leg-raising test showed right 60(+) and left 80(-). Findings from standard imaging (magnetic resonance) and collective physical examinations indicated a L5/S1 herniated lumbar disc. Treatment consisted of three-dimensional (balanced regulating) spinal manipulation and acupuncture, upon which the LDH resolved by retraction.

CONCLUSION

Following L5/S1 herniated lumbar disc diagnosis, three-dimensional (balanced regulating) spinal manipulation combined with acupuncture therapy is an effective treatment.

Neuro-anesthesiology in pregnancy

Management of the pregnant patient requiring neurosurgery poses multiple challenges, juxtaposing pregnancy-specific considerations with that accompanying the safe provision of intracranial or spine surgery. There are no specific evidence-based recommendations, and case-by-case interdisciplinary discussions will guide informed decision-making about the timing of delivery vis-à-vis neurosurgery, the performance of cesarean delivery immediately before neurosurgery, consequences of neurosurgery on subsequent delivery, or even the optimal anesthetic modality for neurosurgery and/or cesarean delivery. In general, identifying whether increased intracranial pressure poses a risk for herniation is crucial before allowing neuraxial procedures. Modified rapid sequence induction with advanced airway approaches (videolaryngoscopic or fiberoptic) allows improved airway manipulation with reduced risks associated with endotracheal intubation of the obstetric airway. Currently, very few anesthetic drugs are avoided in the neurosurgical pregnant patient; however, ensuring access to critical care units for prolonged monitoring and assistance of the respiratory-compromised patient is necessary to ensure safe outcomes.

Arnold-Chiari malformation and significant lumbar disc prolapse in pregnancy: A case report and literature review

A 30-year-old woman (gravida 3, para 1 + 1), with a previous uncomplicated pregnancy and vaginal delivery, was diagnosed with both type 1 Arnold-Chiari malformation and symptomatic multi-level lumbar disc prolapse in her inter-pregnancy period. During this index pregnancy, she experienced progressively worsening occipital headaches radiating to both arms, severe low back pain radiating to both legs and weakness in both legs. She had no urinary or bowel symptoms. She was successfully managed through pregnancy by a multidisciplinary team that included obstetricians, orthopedic and neurosurgeons, obstetric anesthetists and physiotherapists. She had an uncomplicated cesarean delivery under spinal anesthesia. As far as we can tell, this is the first report of both conditions in a pregnant woman.

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Arnold-Chiari malformation in pregnancy is rare.

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Patient care is best individualized and managed by a multidisciplinary team.

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Regional and general anesthesia can have patient specific challenges for women with Arnold Chiari malformation in pregnancy.

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Women with disc prolapse in pregnancy need urgent MRI and neurosurgical review for new or worsening neurological symptoms.

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Spinal decompression surgery can be performed at all stages of pregnancy when indicated.

The Management of Symptomatic Lumbar Disc Herniation in Pregnancy: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Lumbar disc herniation (LDH) has been reported to affect 1 in 10 000 pregnant women. There is limited evidence available regarding the optimal management of LDH in pregnant patients. We aimed to review the current evidence for the management of symptomatic LDH in pregnancy through critical appraisal and analysis of the available literature.

METHODS

Searches were conducted in Medline, Embase, PubMed, Science Direct, and The Cochrane Library from inception using predetermined search terms. All peer-reviewed studies of pregnant women with symptomatic LDH were included. The quality of eligible articles was assessed and extracted data and characteristics were pooled for analysis. References cited by studies were screened to identify other relevant publications.

RESULTS

Thirty studies involving 52 patients were identified. Compared to surgically managed patients, conservatively managed patients had a higher full recovery rate (61.54% vs 56.41%) and reported a lower rate of persistent symptoms (30.77% vs 38.54%). Compared to patients who were treated surgically for cauda equina syndrome, patients treated surgically for sciatica had a higher full recovery rate (80.95% vs 27.78%) and reported a lower rate of persistent symptoms (14.29% vs 66.67%).

CONCLUSION

There is limited evidence to guide the management of pregnant patients with LDH. Despite a suggestion toward improved outcomes with conservative management, the presence of selection bias and the overall poor quality of current research precludes reliable conclusions from being drawn. Decision making for this patient group should be undertaken within a multidisciplinary setting.

Spinal Emergency Surgery During Pregnancy: Contemporary Strategies and Outcome

BACKGROUND

Low back pain is a common complaint during pregnancy. However, spinal pathologies, which manifest with severe pain, radiculopathy, and acute neurologic deficits because of disk herniation or mass lesions require special attention. Here, we present our interdisciplinary experience in the surgical management of spinal emergencies during pregnancy.

METHODS

The data of pregnant women who underwent surgery for spinal pathologies over a 10-year period were collected. Patient-related characteristics such as maternal age, gestational age, preoperative workup, signs and symptoms of mothers, and diagnostic procedures were evaluated. After an interdisciplinary conference, individualized treatment plans regarding available options were developed. Fetal Doppler and cardiotocography were obtained before and after surgery.

RESULTS

Nine pregnant women presented with spinal disorders and underwent spinal emergency surgery within the study period. The mean maternal age was 32.2 years. Six women presented with lumbar disk herniations manifesting as severe sciatica or foot drop and 3 patients had thoracic mass lesions resulting in cauda equine syndrome and/or ataxia. The mean gestational age at the time of presentation was 26.5 weeks. Caesarean sections were performed in 3 women prior to the neurosurgical procedure, whereas the pregnancies were maintained in the 6 other patients. Eight infants who were healthy at birth had an unremarkable development.

CONCLUSIONS

Surgery for spinal emergencies in pregnancy can be performed safely according to individual treatment plans developed by an interdisciplinary team taking into account the expectant mother's decision. Maintenance of pregnancy is possible and feasible in most patients.

Physical Activity for the Treatment of Chronic Low Back Pain in Elderly Patients: A Systematic Review

Chronic low back pain (CLBP) affects nearly 20-25% of the population older than 65 years, and it is currently the main cause of disability both in the developed and developing countries. It is crucial to reach an optimal management of this condition in older patients to improve their quality of life. This review evaluates the effectiveness of physical activity (PA) to improve disability and pain in older people with non-specific CLBP. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to improve the reporting of the review. Individual risk of bias of single studies was assessed using Rob 2 tool and ROBINS-I tool. The quality of evidence assessment was performed using GRADE analysis only in articles that presents full data. The articles were searched in different web portals (Medline, Scopus, CINAHL, EMBASE, and CENTRAL). All the articles reported respect the following inclusion criteria: patients > 65 years old who underwent physical activities for the treatment of CLBP. A total of 12 studies were included: 7 randomized controlled trials (RCT), 3 non-randomized controlled trials (NRCT), 1 pre and post intervention study (PPIS), and 1 case series (CS). The studies showed high heterogeneity in terms of study design, interventions, and outcome variables. In general, post-treatment data showed a trend in the improvement for disability and pain. However, considering the low quality of evidence of the studies, the high risk of bias, the languages limitations, the lack of significant results of some studies, and the lack of literature on this argument, further studies are necessary to improve the evidences on the topic.

Robotic Spine Surgery and Augmented Reality Systems: A State of the Art

Instrumented spine procedures have been performed for decades to treat a wide variety of spinal disorders. New technologies have been employed to obtain a high degree of precision, to minimize risks of damage to neurovascular structures and to diminish harmful exposure of patients and the operative team to ionizing radiations. Robotic spine surgery comprehends 3 major categories: telesurgical robotic systems, robotic-assisted navigation (RAN) and virtual augmented reality (AR) systems, including AR and virtual reality. Telesurgical systems encompass devices that can be operated from a remote command station, allowing to perform surgery via instruments being manipulated by the robot. On the other hand, RAN technologies are characterized by the robotic guidance of surgeon-operated instruments based on real-time imaging. Virtual AR systems are able to show images directly on special visors and screens allowing the surgeon to visualize information about the patient and the procedure (i.e., anatomical landmarks, screw direction and inclination, distance from neurological and vascular structures etc.). The aim of this review is to focus on the current state of the art of robotics and AR in spine surgery and perspectives of these emerging technologies that hold promises for future applications.

Positioning issues of spinal surgery during pregnancy

BACKGROUND

Albeit rarely, different spinal pathologies may require surgical treatment during pregnancy. The management of such cases poses a series of challenges, starting with adequate body positioning.

OBJECTIVE

To illustrate limits and indications of the different surgical positioning strategies for pregnant women undergoing spine surgery.

METHODS

We performed a systematic review of literature about the described surgical positioning strategies used for spinal surgery during pregnancy, discussing advantages, indications, and limits. We also describe of a novel three-quarters prone positioning for dorsal pathology.

RESULTS

The surgical strategy may vary according to several factors, such as the location and the nature of the underlying pathology, the stage of the pregnancy, and the clinical condition of mother and fetus. During the second trimester, the habitus begins to raise issues about both the abdominal and the aortocaval compressions. The third trimester implies neonatal and ethical challenges: both fetal monitoring and the possibility of urgently proceeding to delivery should be guaranteed. The prone position is feasible during the second trimester provided an adequate frame is supplied. The lateral or three-quarters prone positioning may offer the safest option in the last stages of pregnancy, whereas both supine and sitting positionings are anecdotal.

CONCLUSIONS

Gestational age, surgical comfort and maternofetal safety should be balanced by a multidisciplinary team to tailor an adequate positioning plan for each individual case. The early third trimester is the more limiting period because of the womb hindrance favoring lateral or three-quarters positionings.

Lumbar Intervertebral Disc Degeneration as a Common Incidental Finding in Young Pregnant Women as Observed on Prenatal Magnetic Resonance Imaging

Background: Obstetric imaging, subserving fetal evaluation, may yield incidental maternal findings. Based on prenatal magnetic resonance (MR) imaging, this study aims to investigate incidental intervertebral disc degeneration and displacement in young, pregnant women. Methods: This retrospective study included the sagittal 1.5 Tesla, T2-weighted lumbar spine images of 943 pregnant Central Europeans (age range, 18-47 years), who initially had undergone MR imaging because of sonographically suspected fetal abnormalities. Qualitatively, 4715 lumbar intervertebral discs were evaluated for degeneration using a modified Pfirrmann MR classification (nondegenerated, low-grade, moderate, and high-grade degeneration), as well as for displacement. In addition to descriptive statistics, an ordinal regression analysis was performed to analyze the relationship between degeneration and the women's age, and body weight. Results: With regard to the highest degree of degeneration in each woman, 578 (61.3%) showed low-grade, 211 (22.4%) moderate, and 154 (16.3%) high-grade degeneration, and no woman had entirely nondegenerated discs. For the span from 18 to 47 years of age, moderate and high-grade degeneration increased from 6.7% to 36.7% and from 13.3% to 22.4%, respectively. Of 943 women, 57 (6%) had disc displacements, of which 97% were in conjunction with high-grade degeneration. There was a statistically significant relationship (p < 0.001) between degeneration and age, and between degeneration and body weight. Conclusions: In young pregnant women, lumbar intervertebral disc degeneration is a ubiquitous, incidental finding, increasing from the late second decade of life onward, which may be part of physiological aging, as opposed to a small percentage of incidental disc displacements.

Management of Herniated Lumbar Disk Disease and Cauda Equina Syndrome in Pregnancy

Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.

Cauda equina syndrome in an obese pregnant patient secondary to double level lumbar disc herniation - A case report and review of literature

Introduction

Lumbar disc herniation during pregnancy poses a significant challenge to the spine surgeon towards achieving good clinical, maternal, and fetal outcomes. Surgical intervention is warranted in patients with significant neural deficits, and cauda equina syndrome and needs to be performed at the earliest in order to avoid irreversible neurological sequelae.

Case presentation

We report a 29-year-old primigravida in her 21st week of gestational period, who was diagnosed with cauda equina syndrome secondary to two level lumbar disc herniations. The lengthier surgical duration in performing double level disc herniations in an obese patient raises concerns in anesthetic dosing of drugs and surgical positioning which may result in fetal distress. A double level decompression and discectomy in prone position was done under general anesthesia. Despite the surgical challenges, the postoperative period was uneventful resulting in immediate pain relief and complete neurological recovery, followed by the delivery of a 2.7-kg healthy male child.

Discussion

Surgical intervention can be performed in pregnancy, to avoid irreversible neurological deficits, even in an obese individual with double level lumbar pathology. However, it is essential that the surgeon appraises the situation and involves an integrated multidisciplinary team comprising anesthetist, spine surgeon, obstetrician, and psychologist, and inculcates certain precautions in the perioperative management to achieve good surgical and fetal outcomes.

SURGICAL TREATMENT OF LUMBAR DISC HERNIATION IN PREGNANT WOMEN: REPORT OF TWO CASES AND A SYSTEMATIC REVIEW

ABSTRACT Objective: To review the surgical treatment of lumbar disc herniation in pregnancy. Methods: We systematically reviewed cases of surgical treatment of pregnant patients with lumbar IVD herniations in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. We searched on electronic databases, including PubMed, Scopus, and Google Scholar, to find relevant articles by keywords. Results: A literature review of 42 cases is presented. Conclusions: The authors’ own data and the literature data demonstrate that decompression surgery in pregnancy is effective and safe for both mother and fetus; however, radical surgery (fusion) can lead to very adverse sequelae for the fetus. Level of Evidence III; Systematic reviewb of Level III studies.

Microsurgical sequestectomy at 36 weeks of pregnancy: A case report

About 30% of pregnant women experience lower back pain. The cause is usually increased mechanical stress combined with the ligament laxity induced by relaxin. Rarely, lower back pain is related to disc herniation. We report such a case, where microsurgical sequestectomy was performed at 36 weeks and three days of gestation because of severe extensor paresis of the left foot and big toe. The case shows that microsurgical treatment during pregnancy is safe. After treatment the patient regained full motor function and her pain regressed. She had a spontaneous vaginal delivery at 38 weeks.

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Disc prolapse in pregnancy is rare.

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We report a case of lumbar disc prolapse at 36 weeks' gestation where microsurgical sequestectomy was undertaken.

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Motor function was restored and pain regressed after the procedure.

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Spontaneous vaginal delivery occurred at 38 weeks.