2025 Volume 12 Pages 261-265
Low back pain during pregnancy is common. However, lumbar disc herniation in pregnancy is rare, and when severe, it can cause lower extremity pain that resists conservative treatment or lead to cauda equina syndrome. In this report, we describe a case of severe lower back pain that did not improve with conservative treatment, necessitating surgery at 12 weeks of gestation. Additionally, we reviewed the literature. A 35-year-old woman, 7 weeks pregnant, presented to our outpatient clinic with right lower extremity pain. Magnetic resonance imaging revealed a herniated disc at the right L4/5. Acetaminophen, a pregnancy-safe analgesic was prescribed. Despite initiating treatment, the pain persisted, and the patient was hospitalized for bed rest. After one month of conservative treatment with no relief, a repeat magnetic resonance imaging showed an enlarged herniated disc. After consulting with the patient and her family, surgery was performed at Kobe University Hospital, which offers comprehensive neurosurgery, obstetrics and gynecology, and anesthesiology services. At 12 weeks of gestation, the patient underwent a microscopic discectomy in the prone position under general anesthesia. Fluoroscopy for surgical level confirmation was minimized. The surgery lasted approximately 1 hour, and the right lower extremity pain was alleviated. Five months later, the patient delivered a healthy child. We report a case of surgery for a herniated disc during pregnancy, along with a review of the literature.
Low back pain during pregnancy is common, affecting more than 50% of pregnant women.1) However, symptomatic herniated discs are rare and may require surgical intervention if symptoms become severe. Given the patient's pregnancy, special consideration was necessary. In this study, we performed surgery with favorable results on a 12-week pregnant woman with symptomatic lumbar disc herniation who had not responded to conservative treatment. We also discuss the indications for surgery, timing, and surgical position, and provide a literature review.
A 35-year-old female presented to our outpatient clinic with complaints of low back pain and right lower extremity pain that began 2 months before her visit. At the onset of pain, she was 7 weeks pregnant. A lumbar spine magnetic resonance imaging (MRI) scan revealed a herniated disc in the right L4/5 region (Fig. 1). Since the patient was pregnant, acetaminophen was prescribed for pain relief, and she was placed under observation. However, her pain did not improve, and she was admitted for treatment and bed rest. As her pain persisted, several epidural blocks were administered. After a repeat MRI, an enlarged herniated disc was confirmed (Fig. 2). After consulting with the patient and her family, she requested surgery. The surgery was performed at Kobe University Hospital, where obstetrics, anesthesiology, and neurosurgery services are available.
Lumbar T2-weighted magnetic resonance image at 7 weeks of pregnancy revealed a herniated disc at L4/5.
Preoperative T2-weighted magnetic resonance image revealed an enlarged right L4-5 disc herniation.
At our institution, we typically perform one of these 2 types of surgery, depending on the case. While we believe full endoscopic discectomy is minimally invasive and leaves a smaller wound, we opted for microscopic discectomy because it requires less time using fluoroscopy for puncture and sheath placement.
The operation was conducted under general anesthesia, with the patient in the prone position, ensuring no abdominal compression and fetal heart rate monitoring was employed. Lateral fluoroscopy was performed twice: once when positioning the patient and once when placing the retractor. The herniated disc was removed under a microscope through an approximately 3 cm skin incision, and the surgery lasted about 1 hour.
Five months later, the patient successfully delivered the baby, and the pain in her right lower leg had resolved.
Low back pain is a common symptom during pregnancy, affecting more than 50% of women, most often during the fifth to seventh months.1) This pain is attributed to hormonal changes (such as relaxin, progesterone, and estrogen)2) and musculoskeletal changes related to pregnancy.3) Relaxin causes softening of collagen fibers, which leads to stretching of the posterior longitudinal ligament and fibrous rings, potentially resulting in intervertebral disc herniation.2) Lumbar disc herniation during pregnancy is typically treated conservatively, but surgery may be required in cases of severe leg pain or cauda equina syndrome.
In general, lumbar disc herniation can heal spontaneously, and conservative treatment is often prioritized. However, not all conservative treatments can be applied to pregnant women due to potential risks to the fetus.
Regarding analgesic use, pethidine and acetaminophen are safe for pain relief during pregnancy.4) The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in early pregnancy may increase the risk of congenital anomalies, particularly cardiac septal defects.5)
Nerve and local blocks may also be effective alternatives to analgesics. However, long-term steroid use is associated with a high risk of adverse fetal effects, including fetal weight loss, respiratory motility issues, fetal heart rate variability, and an increased risk of early-onset neonatal sepsis.6)
If pain control proves difficult with these limited conservative treatments, surgical intervention may be necessary, considering the gestational age of the pregnancy.
The frequency of lumbar discectomy during pregnancy is reported to be very low, with approximately 1 in 10,000 individuals affected.7) Nyrhi et al.8) reported an incidence of 11 operations per 100,000 individuals and 47 operations per 100,000 person-years for lumbar discectomies during pregnancy and 12 months postpartum, respectively, in Finland. Most lumbar discectomies were performed during the first 2 trimesters of pregnancy, with a mean pregnancy duration of 15 ± 3 weeks at the time of surgery. Approximately 12% of operations were performed in the third trimester.
It is well-established that drugs, radiation exposure, and other factors during the organogenesis phase of pregnancy can lead to fetal malformations. Surgery during this period should be avoided. However, as the pregnancy progresses into the second half, the fetus grows larger, making it more difficult to perform surgery in the prone position. Since the surgery was performed at 12 weeks of gestation, we chose to perform it in the prone position.
Table 1 summarizes previous reports we retrieved. With the exception of 1 case performed at 5 weeks of gestation,9) most surgeries were performed after the eleventh week of pregnancy,10-26) with a greater number of cases performed in the lateral position as gestational age increased.9,12,13,19,20,24,25) In pregnancies after 34 weeks, there have been reports of herniated disc surgery performed in the prone position after Cesarean section.15,17,21,22)
Reported Cases of Herniated Disc Surgery Performed During Pregnancy or After Cesarean Section
| Year | Author | Journal | Age | Week of Pregnancy | Affected Disc | Position | |
|---|---|---|---|---|---|---|---|
| 2021 | Mitha R (10) | Surg Neurol Int | 25 | 17 | L4/5 | Prone | |
| 2019 | Raja DC (11) | Spinal Cord Ser Cases | 29 | 21 | L3/4, L4/5 | Prone | |
| 2019 | Ahern DP (9) | Clin Spine Surg | 29 | 36 | L5/S1 | Left lateral | |
| 37 | 12 | L5/S1 | Prone | ||||
| 33 | 5 | L5/S1 | Prone | ||||
| 2018 | Kovari VZ (12) | Eur Spine J | 35 | 32 | L5/S1 | Right lateral | |
| 2017 | Hayakawa K (13) | Spine (Phila Pa 1976). | 38 | 24 | L4/5 | Left lateral | |
| 2015 | Kanas M (14) | Global Spine J | 35 | 18 | L4/5 | Prone | |
| 2015 | Geftler A (15) | Isr Med Assoc J | 33 | 36 | L4/5 | Prone | Cesarean section |
| 2015 | Martel CG (16) | Ochsner J. | 27 | 27 | L3/4 | Prone | |
| 2014 | Ochi H (17) | Int J Surg Case Rep | 33 | 34 | L4/5 | Prone | Cesarean section |
| 2012 | Hakan T (18) | J Neurosci Rural Pract | 34 | 25 | L5/S1 | Prone | |
| 2011 | Lee JM (19) | Korean J Spine | 32 | 20 | L4/5 | Left lateral | |
| 2008 | Han IH (20) | Spine (Phila Pa 1976) | 32 | 11 | L4/5 | Prone | |
| 30 | 11 | L4/5, L5/S1 | Prone | ||||
| 30 | 15 | L5/S1 | Right lateral | ||||
| 30 | 32 | L4/5 | Left lateral | ||||
| 33 | 30 | L4/5 | Left lateral | ||||
| 34 | 26 | L4/5 | Right lateral | ||||
| 2008 | Gupta P (21) | Eur J Obstet Gynecol Reprod Biol | 37 | 35 | L5/S1 | Prone | Cesarean section |
| 2007 | Al-areibi A (22) | Can J Anaesth | 33 | 35 | L5/S1 | Prone | Cesarean section |
| 2006 | Abou-Shameh MA (23) | Int J Gynaecol Obstet | 34 | 18 | L4/5 | Prone | |
| 2006 | Kathirgamanathan A (24) | Int J Obstet Anesth | 34 | 33 | L4/5 | Left lateral | |
| 2004 | Iyilikci L (25) | J Anesth | 31 | 20 | L5/S1 | Left lateral | |
| 2001 | Brown MD (26) | Spine | 41 | 20 | L5/S1 | Prone | |
| 31 | 20 | L5/S1 | Prone | ||||
| 32 | 16 | L5/S1 | Prone |
In recent years, it has been reported that the majority of lumbar disc herniations during pregnancy occur in individuals aged >30 years.26) The number of cases presenting with symptomatic lumbar disc herniation is increasing, likely due to older pregnancies and obesity.4)
At our institution, we perform 2 types of lumbar disc herniation surgeries: microscopic discectomy and full endoscopic discectomy (FED). The FED transforaminal approach is minimally invasive with a small wound but requires fluoroscopic confirmation at the time of disc puncture and sheath placement. If the interlaminar approach is chosen, the fluoroscopy is similar to that of microsurgery. However, due to the possibility of a longer operation time, we opted for microsurgery in this case.
Kapetanakis et al.27) performed surgery for a herniated disc during pregnancy and found that it can be performed under local anesthesia, involves a small wound, and is minimally invasive. However, fluoroscopy is essential in full-endoscopic techniques to guide the entire procedure, from verifying the corresponding level to passing the dilators and reamers.
Although slightly more invasive than endoscopic surgery, microscopic discectomy is a useful procedure for pregnant women because it minimizes the use of fluoroscopy.
We reported a case of surgery for a herniated disc at 12 weeks of gestation. Therefore, surgery is feasible with adequate preparation, but conservative treatment should be preferred if possible.
Informed consent was obtained from the patient for the publication of this case report.
There are no conflicts of interest.
