Title : Lumbar disc compression with foot drop in pregnancy: Managing mother and baby
Abstract:
Introduction: Lower back pain affects approximately 30% of pregnancies. Disc herniation during pregnancy is rare (incidence of 1:10,000)1 and poses significant management challenges and risks progression to cauda equina syndrome (CES). We present a case of severe L4/5 radiculopathy in pregnancy, highlighting the complexity of shared decision-making between obstetrics, anaesthesia, neonatal and neurosurgery teams.
Case Report: A 29-year-old para 1 presented at 25 weeks gestation to obstetric anaesthesia high risk clinic with severe right sided sciatica, refractory to conservative management. A slipped disc 4 years ago was treated by steroid injections. Her first pregnancy was uneventful, and she delivered by elective caesarean section under neuraxial anaesthesia. During this pregnancy from 23 weeks gestation she noticed progressive right back and hip pain worse on sitting and standing. MRI spine at 23 and 25 weeks showed a large right sided posterior L4/5 disc herniation. Her pain and symptoms progressed to a complete right foot drop between 26 – 29 weeks, without red flag symptoms such as perineal numbness or urinary/fecal incontinence. Lumbar epidural injection under ultrasound guidance for symptom relief was performed with a good outcome. Repeat MRI at 30 weeks showed interval enlargement of L4/5 disc protrusion with significant canal stenosis and radiological CES.
Urgent MDT discussions were undertaken for timing of spinal surgery versus delivery. Specific considerations included spinal surgery in the lateral position, fetal monitoring during general anaesthesia (GA) and delivery under neuraxial versus GA. From 28 weeks she stayed in hospital and was reviewed daily by MDTs, received steroids and magnesium. She opted for elective caesarean section at 32 weeks gestation under GA, followed by L5 laminectomy & L4/5 microdiscectomy the next day. Mother and baby were discharged at day 6 with improving mobility and a resolving R foot drop.
Discussion: Most cases of disc herniation are treated conservatively. Surgery is performed mostly in first or second trimester (88% vs.12% of operations in third trimester)2. Early recognition and prompt MDT involvement is essential, because delays in decompression are associated with poorer neurological outcomes.
This case highlights the importance of individualized, patient-centred decision-making. Anaesthetists play a key role in coordinating MDT discussions, risk stratification, and planning anaesthetic management for both delivery and neurosurgical intervention. Reporting such cases contributes to the limited literature and may support future guidance for managing CES in pregnancy.
