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

Regional anesthesia in spine surgery: A narrative review

Background: Regional anesthesia, which refers to the use of anesthetics to provide analgesia to a specific body part or nervous innervation territory, has become increasingly popular in the field of spine surgery. With the application of these techniques, it has been postulated that patients will require less systemic analgesia, intraoperatively and postoperatively. The authors of this narrative review discuss the common regional anesthetic modalities applied to spine surgery, in addition to patient selection criteria, success in patients with multiple comorbid illnesses, and its adoption by surgeons. Materials and Methods: An advanced search was performed in the PubMed database to obtain Englishlanguage articles discussing regional anesthesia, awake spine surgery, and postoperative complications. Articles were screened for relevance, and 47 articles were incorporated into this narrative review. Results: Classic neuraxial and paraspinal techniques have allowed surgeons to perform posterior decompression, fusion, and revision procedures. Transversus abdominus plane and quadratus lumborum blocks have enabled better pain control in patients undergoing surgeries requiring anterior or lateral approaches. Documented benefits of regional anesthesia include shorter operative time, improved pain control and hemodynamic stability, as well as decreased cost and length of stay. Several case series have demonstrated the success of these techniques in highly comorbid patients. Conclusion: Regional anesthesia provides an exciting opportunity to make surgical treatment possible for spine patients with significant comorbidities. Although additional randomized controlled trials are necessary to further refine patient selection criteria, current data demonstrates its safety and efficacy in the operating room.

Musculoskeletal steroid injections in pregnancy: a review

Pregnant women experience a wide range of musculoskeletal pain disorders, which include general ailments occurring during pregnancy, exacerbation of pre-existing conditions, or pregnancy-specific pain/inflammatory conditions. There are significant concerns and knowledge gaps surrounding the safety, dosage, and potential long-term effects of several drugs used during pregnancy. Our article reviews the use of focal steroid injections during pregnancy. A mixture of case studies, meta-analyses, and randomised controlled trials have shown at least there is no adverse side effect to the mother or baby from maternal use of non-systemic injection during pregnancy and a significant improvement in symptoms of pain or paraesthesia can be achieved in patients that do not respond to more conservative measures. As with all patients, the use of steroid injection should be judged on a case-by-case basis to ensure that it is the most appropriate treatment choice. However, being pregnant should not be considered a contraindication to a single dose of non-systemic steroid administration, as these women can achieve significant symptomatic relief that reduces reliance on systemic medication and can significantly improve their quality of life.

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.