Spine and joint disorders in late prenatal – maternal care management options

1. Spine and joint disorders in late prenatal – maternal caremanagement options

2. Outline • Introduction • Low back and pelvic pain in general • General considerations and Hormonal considerations • Mechanical explanations for back and pelvic pain in pregnancy • Lumbar disc disease • Vascular congestion and night backache • Sacroiliac pain, osteitis condensans illii, and an associated with the inflammatory processes • Risk factors • Evaluations • Treatment

3. Outline Specific conditions – risks and management options • Spondylolysis and spondylolithesis • Scoliosis • Pelvic arthropathy and pubic symphysis rupture • Postpartum osteitis pubis • Stress fractures of the pubic bone • Transient osteoporosis of the hip • Avascular necrosis of the hip • Hip arthroplasty

4. Complaints of musculoskeletal discomfort during pregnancy are common and may be temporarily disabling • Problems usually resolve spontaneously with completion of pregnancy • Some conditions that exist prior to pregnancy may effect the course of the pregnancy

5. Physiologic change in musculoskeletal system • Progressive lordosis • Compensating for anterior position of the enlarging uterus • Increased mobility of sacrococcygeal , sacroiliac and pubic joints

6. Physiologic change inmusculoskeletal system • Aching, numbness and weakness of upper extremities mark lordosis with anterior neck flexion and slumping of the shoulder girdle traction of ulnar and median nerve

7. Physiologic change inmusculoskeletal system • Most relaxation of symphysis pubis occur in first half of pregnancy and retrogression begins immediately following delivery, usually complete within 3 – 5 months

8. Low back and pelvic pain

9. General considerations • Back and pelvic pain occur in 48 – 90 % of pregnancy • Lumbar pain may be more common during pregnancy in women who noted back pain before pregnancy • Onset during pregnancy is more commonly described as sacral pain

10. Hormonal considerations • Relaxin • A polypeptide hormone • Produced by corpus luteum , deciduas and chorion • Receptor sites / target organs ; pubic symphysis , myometrium , cervix , placenta , breasts and skin fibroblast

11. Hormonal considerations • Relaxin • Thought to relax connective tissue and relax myometrium • Peak in first trimester , decreasing toward the end of gestation, increase again in early labor and undetectable by the third day postpartum • However , the relationship between hormone levels and joint pain in pregnancy is unclear

12. Mechanical Explanations for back and pelvic pain in pregnancy • General weight gain and the weight of the uterus, fetus and breast increaseload on spine • Response in increasing lumbar lordosis ; more anterior center of mass & producing shear stress across the motion segments of lumbar spine • The contribution of abdominal musculature to support the spine may be diminished

13. Mechanical Explanations for back and pelvic pain in pregnancy • Radicular symptoms are common , caused by direct pressure of the uterus on nerve roots and lumbar and sacral plexus • Mechanical pressure on nerve roots by ligamentous structures of increasingly lordotic spine “ parietal neuralgia of pregnancy “

14. Lumbar disc disease • Relaxin may weaken the annulus of the intervertebral discs • Less studies related lumbar disc disease to pregnancy • Potential for disc herniation and lumbar nerve root compression, with radicular pain and definite neurologic loss should be considered • EMG , MRI may helpful in diagnosis

15. Vascular congestion and night backache • Increased venous flow through lumbar veins, the vertebral plexus , and paraspinal and azygous vein • Mechanical vena cava compression in supine position

16. Sacroiliac pain • Inflammatory changes in the sacroiliac joint • Osteitis condensans illii • Fairly uniform area of increased density in the lower iliac bone, adjacent to the sacroiliac joint ,unilateral or bilateral • Most common in women, particularly in pregnancy

17. Risk factors: during pregnancy • Increasing parity • Younger age • Back pain before pregnancy • Increased lordosis before pregnancy • Smoking • Physically strenuous work • Physical heaviness of work • Sitting work posture • Frequency of twisting and forward bending

18. Risk factors : postpartum pain • Twin pregnancy • First pregnancy • Higher age at first pregnancy • Increased weight of the baby • Forceps or vacuum extraction • Flexed position of the women at childbirth • Cesarean section is negatively associated with postpartum pain

19. Evaluations • Consider extraskeletal causes for backache • Atypical presentations or pain refractory to the usual care may indicate more significant, although rare , pathology • Differentiation from similar symptoms from direct fetal pressure on nerve roots is necessary • Routine examination and specific tests

20. Evaluations • Specific test • Straight-leg raising test • PSIS pressure in the standing • Sacrospinous and sacrotuberous ligament pressure • Pubic symphysis pressure • Femoral compression test ( thigh thrust test ) • Iliac or ventral gapping test, dorsal gapping test • Patrick test • Pelvic torsion ( Gaenslen test ) • Fortin finger test

21. Straight leg raising test

22. Sacrospinous & sacrotuberous ligament tenderness suggest a pelvic contribution to the pain

23. Femoral compression test / posterior shear -Sacral area or ipsilateral buttock Iliac compression test -sacral and buttock

24. Patrick test -sacroiliac area Pelvic torsion / Gaenslen

25. Evaluations • Radiographic evaluation • Plain film • Lumbar spine x-ray 0.031 to 4.0 RADS • Pelvis XRAy (AP) < 2.2RADS • Ultrasound • MRI • Electromyography and nerve conduction study

26. Harmful Radiation Levels to fetus • RADS : 5 -10 • Fetal Exposure in first 47 days: Spontaneous Abortion • Fetal Exposure after 47 days: Live fetus • Risk of congenital malformation increased 1 to 3% • Mental retardation and other CNS effects • Microcephaly • Intrauterine Growth restriction • First trimester exposure (especially <8 weeks) • Risk of childhood cancer • RADs: 200 • Infertility Risk • Higher risk to fetus in early pregnancy

27. Treatments • Rest • Daily low back exercise • Pelvic tilt exercise • Simple measure taught in back care programs; placing one foot on afoot stool when standing • Maternity cushion • Elastic compression stocking • Trochanteric belt for posterior pelvic pain

28. Low back exercise

31. Maternity cushion

32. Elastic compression stocking and belt

33. Treatments • Analgesic agents • Lumbar epidural steroids • Transcutaneous electrical nerve stimulation • Sacroiliac injection with corticosteroids and local anesthetic in severe care

34. Analgesics • Class B: No risk in controlled animal studies • Acetaminophen (Tylenol) • Analgesic of choice in pregnancy • Narcotics (Class D if prolonged use or high dose) • Fentanyl (Duragesic) • Morphine Sulfate • NSAIDs (first or second trimester only) • Ibuprofen (Motrin) • Indomethacin (Indocin) • Naproxen (Naprosyn) • Piroxicam (Feldene)

35. Analgsics • Class C: Small risk in controlled animal studies • Narcotics (Class D if prolonged use or high dose) • Codeine (Tylenol with codeine • Tramadol (Ultram) • NSAIDs (first or second trimester only) • Aspirin • Class D: Strong evidence of risk to the human fetus • Aspirin • Used only with specific indications in pregnancy • Risk of neonatal hemorrhage, IUGR, perinatal death • Low dose Aspirin may be safer • All NSAIDs (Third Trimester)

36. Lumbar epidural steroids

37. TENS • transmission of low-voltage electrical impulses from a handheld battery-powered generator to the skin via surface electrodes

38. Sacroiliac injection

39. Spondylolysis and spondylolithesis

40. Spondylolysis • a bony insufficiency at the par interarticularis os the spine • Can cause instability and pain

41. Spondylolithesis • The slipping forward of one vertebra on another • Can result from a spondylolytic defect or from degenerative change in the facet joints • Common in males than females , but higher chance of progression in female • Common occur at the L5-S1

42. No significant differences in symptomatology , impairment, degree of slip , or progression of slip in men , nulliparous and parous wome • Spondylolysis ,with or without spondylolithesis, was not a risk factor for pregnancy complications • Women who had borne children had a significantly higher incidence of degenerative spondylolithesisthan those who was not

43. Management options • Rest and immobilization • Analgesic agent

44. Scoliosis

45. Scoliosis • A three – dimensional deformity of the spine most prominently manifested by curvature in the coronal plane • Usually idiopathic , commonly familial • Common in females than in males

46. No significant increase in the rate and incidence of curve progression during pregnancy • Somes have severe back pain during pregnancy • Spinal anesthesia may not be possible • The incidence of complications or deformity in the newborn was not increased • Postpartum back pain not greater than general population

47. Women of childbearing age with curves greater than 30 degrees , radiographs should be done soon after each delivery

48. Pelvic arthropathy and pubic symphysis rupture

49. Pelvic arthropathy • Occur in two recognizable syndromes • Abnormal mobility of the pelvic joints may lead to pain and waddling gait • After difficult delivery, there may be a ruptue of the symphysis

50. Pelvic arthropathy • Clinical pain with walking, turning to bed , or other exertion,unilateral or bilateral waddling gait • Asymmetrical SI laxity is much more associated with pelvic pain than absolute laxity • Diagnosis : history of pregnancy , pain at the pubic symphysis or SI joints, tender, laxity of ligaments