Surgical Management of the Pregnant Patient With Lumbar Disc Herniation in the Latter Stage of the Second Trimester

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.

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.

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.

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.

Lumbar disk herniation during pregnancy: a review on general management and timing of surgery

STUDY DESIGN

Narrative review with case illustration.

OBJECTIVE

Provide an overview of existing management strategies to suggest a guideline for surgical management of lumbar disk herniation in pregnant women based on time of presentation.

METHODS

We performed a narrative review on the topic using the PubMed database. A total of 63 relevant articles published after 1992 were identified, of which 17 fulfilled selection criteria.

RESULTS

A total of 22 published cases of spine surgery for disk herniation during pregnancy were found in 17 studies on the topic. Prone positioning was reported in the majority of cases during the first and early second trimester. C-sections were performed prior to spine surgery in the prone position for the majority of patients operated during the third trimester. The left lateral position with continued pregnancy was preferred during the latter half of the second trimester when delivery of the fetus cannot yet be performed but surgery is indicated.

CONCLUSION

Spine surgery during pregnancy is a rare scenario but can be performed safely when needed if providers adhere to general guidelines. Surgical approaches and overall management are influenced by the stage of pregnancy.

How to treat lumbar disc herniation in pregnancy? A systematic review on current standards

PURPOSE

In this systematic review, we aim to illustrate the current and safe concepts in the assessment, diagnosis and management of herniated lumbar disc (HLD) during pregnancy.

METHODS

A systematic review and reporting on the diagnosis, treatment and clinical results of HLD during pregnancy is performed.

RESULTS

The MRI represents the first level and safest diagnostic tool for pregnant women affected by spinal problems allowing for a noninvasive and detailed radiological examination of the spine. The initial management of pregnant women affected by HLD is conservative, and primarily aimed to pain therapy. Whenever radicular pain and progressive neurological deficits unresponsive to medical management occur, surgery should be considered. Few case reports regarding the operative management of HLD in pregnant women have been published up to date. Laminectomy and/or microdiscectomy represent the classical and most commonly used techniques that can be safely performed without affecting pregnancy, delivery, or baby's health. Endoscopic discectomy may be an alternative. The most adequate timing and surgical position are chosen based on to the fetal gestational age and site of the pathology.

CONCLUSIONS

Surgical treatments during pregnancy impose multiple medical and ethical problems. Timely diagnosis by MRI, careful clinical evaluation, and surgical treatment represent safe and effective procedures. Ongoing evolution of surgical, anesthesiological and obstetrical procedures results in favorable outcomes. However, interdisciplinary management and a wide knowledge of pregnancy-related pathologies are crucial for the best outcome for both mother and child.