ESI in a pregnant patient. Would you do it?

[camkiss]

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I have a patient in my pain clinic who presents with severe unilateral radiculopathy. No neuro findings, no prior history, just severe pain. She's been admitted to the hospital twice now for pain control. She is in her early third trimester. Narcotics are not really helping her pain, nor is PT or oral steroids. I can't find any literature regarding doing a blind interlaminar ESI without fluoro in a pregant patient. There are anecdotal comments on community forums from ladies who say they received ESI's while pregnant, but nothing official. Any thoughts from the gurus here?

 

[Intubate]

Its never come up for me, but I guess I'd just do a crappy old blind interlaminar ESI. Not going to fluoro her. It might help, and its probably not going to hurt. I'd run it by her OB. Probably your only option other than doing nothing.

 

[emd123]

How about waiting until she delivers the child and seeing if the symptoms go away on their own since likely her symptoms are brought on by the rapid weight gain and altered load on her spine from being 3rd trimester pregnant with all of its altered bio-mechanics? Then ESI after delivery if symptoms aren't improving.

 

[Idiopathic]

because shes been admitted twice for pain control. assuming she isnt a seeker (big assumption) then it seems reasonable, but if shes become dependent on opiates, then its probably very low yield

 

[dhb]

Narcotics are not really helping her pain, nor is PT or oral steroids. I can't find any literature regarding doing a blind interlaminar ESI without fluoro in a pregant patient.

She's already on narcotics and steroids how much is a little fluoro going to harm the baby (3rd trimester)

 

[lobelsteve]

And if the epidural triggers pre-term labor and she loses the baby?

Not likely, but I'm just saying....No way would I.
And if you are, at least let her use the Cambin frame or lie on her side with lateral C-arm position.

 

[jetproppilot]

I have a patient in my pain clinic who presents with severe unilateral radiculopathy. No neuro findings, no prior history, just severe pain. She's been admitted to the hospital twice now for pain control. She is in her early third trimester. Narcotics are not really helping her pain, nor is PT or oral steroids. I can't find any literature regarding doing a blind interlaminar ESI without fluoro in a pregant patient. There are anecdotal comments on community forums from ladies who say they received ESI's while pregnant, but nothing official. Any thoughts from the gurus here?

Her reply to me would be something like

"So, Dr Jet, if hell DOES freeze over..."

 

[PinchandBurn]

Assuming you are an anesthesiologist. You have done hundreds of Epidurals.

Do the epidural w/o fluro. You know where the epidural space is.

Explain the r/b.

To counter Steve's point about preterm labor. This patient can be in so much agonizing pain that that could cause preterm labor. Everything is possible..

At this point, you have exhausted all conservative management (oral steroids,etc). She's been admitted twice now. The kid is 3rd trimester, so depending on how long exactly he/she is, the kid is likely viable. So even if preterm labor occurs, give the kid steroids to assist with maturation of the lungs (obviously consult peds/OB about this).

done.

 

[Gern Blansten]

I have and I would again in this scenario. I would not use fluoro. I would want to do a complete exam to ensure that the pain is truly radicular in nature and not due to SI joint inflammation.

 

[Intubate]

And if the epidural triggers pre-term labor and she loses the baby?

Not likely, but I'm just saying....No way would I.
And if you are, at least let her use the Cambin frame or lie on her side with lateral C-arm position.

How does an epidural cause preterm labor? Why would she lose the baby?

 

[lobelsteve]

How does an epidural cause preterm labor? Why would she lose the baby?

No idea to either , and if it happened even at random- your procedure was elective, done rarely, and led to baby x demise. That's what the lawyer will say and he'll have a hired gun saying you shouldn't have done it.

I stay away from pregnant patients. If my patients become pregnant- we stop meds, no procedures, recharge scs if they are implanted and turn that off. Happy to see post delivery. But I'm all outpatient Pain.

 

[Gern Blansten]

No idea to either , and if it happened even at random- your procedure was elective, done rarely, and led to baby x demise. That's what the lawyer will say and he'll have a hired gun saying you shouldn't have done it.

I stay away from pregnant patients. If my patients become pregnant- we stop meds, no procedures, recharge scs if they are implanted and turn that off. Happy to see post delivery. But I'm all outpatient Pain.

You turn off their SCS? Is there a specific concern or just a general desire not to take care of pregnant patients due to fear of litigation (the whole next 18 years thing)?
As I recall from previous posts, you are PM&R trained (sorry if I misremembered). Anesthesiology trained pain guys spend 3 solid years caring for pregnant ladies with neuraxial blocks. I wonder if your anesthesia trained colleagues feel the same about treating chronic pain in pregnant females. Not ragging on anyone, just curious if that plays a role. My guess is that during PM&R residency training, you probably saw close to zero pregnant ladies. May not be true, but it is my assumption.
Having cared for pregnant females for many years, I have a fairly high comfort level with sticking needles in their back and I have seen that it almost always goes without any problems. Thus, my reasoning for saying I would do it in this refractory pain patient. Being pregnant and having chronic pain are a bad mix and I really feel pity for them. They are suddenly told that they can no longer take any pain meds and the entire 40 weeks they have to make daily decisions that cause them to suffer in the name of avoiding risk to the baby. What a challenge that is.

 

[sevoflurane]

I was wondering this myself. But I'm not a pain guy although I've placed my fair share of LESI. I would be very cautious at stopping all pain meds if they are on high doses. I would think that the physiologic effects of acute withdrawal are serious and outweigh those of a LESI. Some might admit patients to monitor the fetus if you are going to discontinue/taper pain meds. Withdrawal can cause premature uterine contractions and premature labor. Withdrawal in the neonate can be serious and prolonged.

FWIW, I've seen LOTS of moms on methadone, oxycontin, etc, on the OB floor.

I think it comes down to risk vs benefit and each case should be individualized.

Just saying... 🙂

 

[powermd]

It seems we (anesthesiologists, regardless of subspecialty) get very worked up over imaginary medicolegal risks that (may) have no precedent. Have any of you actually heard of an anesthesiologist being sued for a blind ESI performed on a pregnant woman?

Thanks to my indoctrination in medicolegal medicine I tend to choose 'zero risk' over 'low, but I have no idea', but at some point common sense should come into play when a patient is clearly suffering.

 

[PinchandBurn]

You turn off their SCS? Is there a specific concern or just a general desire not to take care of pregnant patients due to fear of litigation (the whole next 18 years thing)?
As I recall from previous posts, you are PM&R trained (sorry if I misremembered). Anesthesiology trained pain guys spend 3 solid years caring for pregnant ladies with neuraxial blocks. I wonder if your anesthesia trained colleagues feel the same about treating chronic pain in pregnant females. Not ragging on anyone, just curious if that plays a role. My guess is that during PM&R residency training, you probably saw close to zero pregnant ladies. May not be true, but it is my assumption.
Having cared for pregnant females for many years, I have a fairly high comfort level with sticking needles in their back and I have seen that it almost always goes without any problems. Thus, my reasoning for saying I would do it in this refractory pain patient. Being pregnant and having chronic pain are a bad mix and I really feel pity for them. They are suddenly told that they can no longer take any pain meds and the entire 40 weeks they have to make daily decisions that cause them to suffer in the name of avoiding risk to the baby. What a challenge that is.

Glad you said it and not me.

I competely agree. After completing an anesthesiology residency, I can say having done oodles of epidurals/spinals on patients even for things like cerclages, that pre term labor doesnt happen with a needle stick. Can I be 100% about that, NO. A pt can go into PTL at any time for a variety of reasons---not necessarily your Touhy needle. I would say that a majority of us anesthesia trained pain physicians would testify (if it came to that) to that end.

I think people's fear secondary to their primary training (no offense STEVE) propagates a lot of unnecessary medicolegal concerns. Patients that are pregnant should not have their meds 'cold turkey' d/c'd. They'll have withdrawls. Even if there's respiratory depression for the baby once it's delievered--you do not give naloxone (if the mom was say on methadone..this was a practice Oral Board question for us).

In terms of SCS...I think it really depends on where it is. If it's in the Thoracic level, why would you turn it off? That patient's FBSS/CRPS or whatever she has the stim in place for isnt going to go away when she's pregnant. Also if the SCS leads are in the Thoracic region and one has to do a neuraxial anesthetic for labor...that's in the LUMBAR region usually and so you avoid damage to the leads...

I would certainly be interested in other people's views on SCS in parturients...