(292) Lumbar Radiculopathy in the Pregnant Patient

Abstract

Lumbar radiculopathy is a common cause of low back and leg pain in many patients. While there are multiple interventions both medical and surgical for the treatment of lumbar radiculopathy, the options become limited in the pregnant patient. We present the case of a 35-year-old female at 25-week gestational age with new onset severe low back and right leg pain. The patient had a history of prior lumbar laminectomy and discectomy for similar symptoms. She presented after failed conservative management with gabapentin and acetaminophen and the pain began to interfere with her daily activities. On presentation to the clinic the patient had severe lumbosacral radiculopathy consistent with Magnetic Resonance Imaging (MRI) findings of a new large disc extrusion on the right. After a discussion of the possible interventions the decision was made to treat the lumbar radiculopathy with caudal epidural steroid injection (ESI) performed under ultrasound guidance. Though there is no set maximum radiation dose deemed safe for the fetus by the American College of Obstetricians and Gynecologists (ACOG), the consensus is to limit the radiation dose to 50mGy before 15-week gestational age and 250mGy thereafter. Ultrasound guided caudal ESI was decided to be the safest course of action to decrease the amount of radiation to the fetus and minimize the risk of dural puncture given her previous laminectomy. Success was confirmed with easy passing of an epidural catheter and a decreased pain score after the procedure. Additionally, during the management of this patient we noted the new classification system from the Food and Drug Administration (FDA) regarding medications in pregnancy. Despite most medication black box warnings maintaining the old category system of A, B, C, D and X; the new FDA system emphasizes the Pregnancy and Lactations Labeling Rule (PLLR) to guide patient discussions and medical management.