Spine surgery during pregnancy [Neurosurgery Wiki]

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====== Spine surgery during pregnancy ======

[[Low back pain]] is a common [[symptom]] in [[pregnancy]] and may be present in up to 56% of pregnant [[women]].

The percentage of [[Caucasian]]s was statistically higher in the back pain group. The percentage of Hispanics was statistically higher in the no pain group. Among the variables that were compared in both groups were the age, the weight gained by the mothers during pregnancy, the baby's weight, the number of previous pregnancies, number of prior children. None of the variables reached a statistically significant level. The pain group complained of pain the low-back area, which radiated in 45.5% of cases to the lower extremities. In about one-third of the patients the pain increased as the day wore on, whereas in another one-third the pain increased during the night and disturbed sleep. Standing, sitting, forward bending, lifting, and walking tended to increase the pain. Most of the patients started suffering from back pain between the fifth and seventh months of pregnancy
((Fast A, Shapiro D, Ducommun EJ, Friedmann LW, Bouklas T, Floman Y. Low-back
pain in pregnancy. Spine (Phila Pa 1976). 1987 May;12(4):368-71. PubMed PMID:
2956698.
)).

Studies correlated low back pain and pelvic pain with increased levels of relaxin, a hormone produced mainly by the corpus luteum during pregnancy. However, biomechanical changes, weight gain, and sagittal imbalance are also possible etiologies
((Kristiansson P, Svärdsudd K, von Schoultz B. Serum relaxin, symphyseal pain,
and back pain during pregnancy. Am J Obstet Gynecol. 1996 Nov;175(5):1342-7.
PubMed PMID: 8942512.
)).

Radiculopathy caused by disk herniation during pregnancy is rare, affecting 1 in 10,000 pregnant women
((LaBan MM, Perrin JC, Latimer FR. Pregnancy and the herniated lumbar disc. Arch
Phys Med Rehabil. 1983 Jul;64(7):319-21. PubMed PMID: 6222717.
)),
but pregnancy at any stage is no contraindication to magnetic resonance imaging scan, epidural and/or general anesthesia, and surgical disc excision
((Brown MD, Levi AD. Surgery for lumbar disc herniation during pregnancy. Spine 
(Phila Pa 1976). 2001 Feb 15;26(4):440-3. PubMed PMID: 11224893.
)).

[[Spine surgery]] during [[pregnancy]] is a rare scenario but can be performed safely when needed if providers adhere to general [[guideline]]s. 

Surgical [[approach]]es and overall [[management]] are influenced by the stage of pregnancy
((Ardaillon H, Laviv Y, Arle JE, Kasper EM. Lumbar disk herniation during
pregnancy: a review on general management and timing of surgery. Acta Neurochir
(Wien). 2018 Jul;160(7):1361-1370. doi: 10.1007/s00701-017-3098-z. Epub 2017 Jan 
31. Review. PubMed PMID: 28144773.
)).

All the previously presented positionings (prone, left lateral) were equally effective regarding the outcome with none being better than another. For left-sided lumbar pathologies performed in the third trimester the right lateral position might be an alternative option for easier access. Based on the literature an epidural and general anesthesia can be applied successfully in the third trimester. Spinal anesthesia might be another anesthesia consideration
((Kovari VZ, Horvath L. Surgical management of cauda syndrome in third trimester
of pregnancy focusing on spinal anesthesia and right lateral positioning during
surgery as possible practices. Eur Spine J. 2018 Feb 22. doi:
10.1007/s00586-018-5519-y. [Epub ahead of print] Review. PubMed PMID: 29470714.
)).

It is necessary to cooperate with a pediatrician, an obstetrician, and an anethesiologists. For obtaining the best outcome on mother and child, it is important to discuss in advance to be able to respond quickly for changeable situation
((Ochi H, Ohno R, Kubota M, Hanyu R, Sakai K, Sugawara Y, Mukasa F, Kaneko K.
Case report: The operation for the lumbar disk herniation just after cesarean
delivery in the third trimester of pregnancy. Int J Surg Case Rep.
2014;5(12):1178-82. doi: 10.1016/j.ijscr.2014.10.055. Epub 2014 Nov 7. PubMed
PMID: 25437670; PubMed Central PMCID: PMC4275852.
)).

Although previously published cases noted the safety of operating in the prone position under epidural anesthesia, we performed minimally invasive microendoscopic discectomy in the left lateral position in combination with general anesthesia and found that this is a safe and preferable alternative for pregnant patients in the latter stage of the second trimester
((Hayakawa K, Mizutani J, Suzuki N, Haas C, Kondo A, Otsuka S, Fukuoka M, Otsuka
T. Surgical Management of the Pregnant Patient With Lumbar Disc Herniation in the
Latter Stage of the Second Trimester. Spine (Phila Pa 1976). 2017
Feb;42(3):E186-E189. doi: 10.1097/BRS.0000000000001741. PubMed PMID: 27310022.
)).