Disc hernia during pregnancy

Pregnancy is a special period in a woman's life. The pregnant woman's body undergoes many major changes, which are quite difficult to manage. However, she adapts to the new circumstances and manages the whole process, usually without any problems.

Significant changes that a woman's body undergoes during pregnancy are the increase in body weight and the anatomical changes in the pelvis, which will accommodate the fetus for nine months, as well as in the spine, which will now have to "carry" a greater load and ... two occupants.

For the above reasons, it is common for pregnant women to experience back pain. Lumbago is defined as any pain in the lower back, regardless of the cause. 

One of the most common causes of lumbar pain is lumbar herniated disc. A herniated disc occurs when the outer layer (fibrous ring) of the intervertebral disc ruptures and part of its soft jelly-like center (pectoid nucleus) leaks into the spinal canal, pressing on nerve structures. 

It is clear, therefore, that hives are painful. Interestingly, this condition may be common in pregnant women, due to the expected weight gain and increased pressure on the spine.

In most cases, women will not experience neurological symptoms due to a herniated disc during their pregnancy. There are, however, exceptions!

A typical example is the case of a pregnant woman, who - being in the 31st week of her pregnancy - came to our clinic with symptoms of cauda equina syndrome (weakness in the movement of the feet, inability to urinate and defecate, numbness in the perinatal area), as early as 12 days when we examined her. Unfortunately for her, it was underestimated when she initially went to the outpatient clinic and a urinary catheter was simply placed.

Having the above neurological picture, he was immediately investigated with an MRI of the lumbar spine, which revealed a large central herniated intervertebral disc. Due to the neurological semiology, a clear indication for immediate surgical treatment with lumbar microdiscectomy (a microsurgical technique where through a very small incision, after localization of the problematic disc, with an X-ray machine and using a microscope - the microscope provides the neurosurgeon with a clear three-dimensional vision through a 'keyhole' - and microsurgical tools, the part of the disc that is pressing on the nerve elements is removed, releasing the nerve elements). Post-operatively, the patient is mobilized the same day and discharged the next day. 

That's all for the average patient... But what about pregnant women?

Microdiscectomy is performed under general anesthesia with the patient in a prone position (prone). Patient in the ^8th month of pregnancy, obviously could not be placed prone. The patient would have to be placed in such a position that the surgical approach could be applied, but also to ensure the integrity of the uteroplacental circulation. For this reason, she was placed in a left lateral tilt position, with continuous monitoring of the fetal heart rate via a connected cardiotocograph. With the help of the Clinic's experienced paramedics, the patient was placed in a left lateral position, which ensures comfort for the patient and the fetus. 

For the surgeon, however, it is particularly difficult, as access to the spine is limited to a minimum and the scope for unnecessary or inappropriate manipulations is practically zero. The assistance of the second surgeon is also limited.

Detecting the level of the lesion with a fluoroscope is impossible. It is forbidden to irradiate the fetus! With the help of our anesthesia team, the space was located using an ultrasound machine.

General anaesthesia in this particular patient is also a challenge. It also answers the common question: can a pregnant woman get general anaesthesia?

Our anesthesiologist is clear. Of course he can! Management with medication that ensures the uterus and fetus are calm helps to reduce surgery time. Regarding the administration of anaesthetic drugs, it was preferred to avoid systemic administration of opioids. Thus, after induction of anaesthesia, intubation and positioning of the patient in the final position, a peripheral block was performed, with the help of ultrasound, in the corresponding thoracic fascia with local anaesthetic. Also, to avoid premature contractions due to surgical stress, intravenous administration of the tocolytic drug ritodrine (prepar) was started preoperatively and continued intraoperatively.

After the pre-operative difficulties were dealt with, the surgery went quickly and the huge piece of disc that was pressing on the nerves was removed. 

The patient during surgery was hemodynamically stable, did not present any adverse event or complication and her awakening from anesthesia was calm and smooth. Also, there was no change in the cardiotocograph. She was transferred for half an hour to the Intensive Care Unit for postoperative observation, where no analgesia was required, and then safely to the ward. The patient was discharged from the Clinic fully mobilised the following day.

Authors: neurosurgical team "Neuronaccess" (Konstantinos Kontogiannis Konstantinos-Moralis Ioannis-Peios Dimitrios-Psarras Nikolaos) and the anaesthesiologist Kopatzidis Elias.