Abstract
Cauda Equina Syndrom
Key Facts
Pregnancy causes several changes to the musculoskeletal system that should be remembered when treating sports injuries during pregnancy. The main changes are a shift in the centre of gravity, increase in body weight and increase in ligament laxity caused mainly by increased relaxing release during pregnancy.
As a result of these changes in pregnancy women are more prone to develop certain musculoskeletal conditions. Some of the common conditions (Table 30.1) are [1]
Low back pain
Hip problems:
Transient osteoporosis avascular necrosis of hip leading to hip pain and even femoral neck fractures [2]
Compression neuropathies and tendonopathies, for example, carpal tunnel syndrome, De Quervain’s tenosynovitis
Leg cramps/deep vein thrombosis
The following bed-side clinical tests may be useful in delineating the site of nerve injury:
Tinel’s test: Light tapping of the median nerve over carpal tunnel causes pain and tingling sensation radiating to lateral three and a half fingers.
Phalen’s test: Hyperflexion of the wrist and holding for about 30 seconds causes numbness over the medial nerve distribution (lateral three and a half fingers).
Finkelstein’s test: Flex the thumb and grasp inside a closed fist, and ulna deviate the hand. This stretches the extensor pollicis brevis and abductor pollicis longus tendon, causing sharp pain along the radial side.
Faber/Patrick’s test: The affected side knee is flexed to 90 degrees and the foot is rested on the opposite knee. The pelvis is firmly held against the table and the affected side knee is pushed towards the examination table; if this causes pain it is more likely to originate from sacro-iliac joint.
| Key implications | Key pointers | Key diagnostic signs | Key actions | Key pearls |
|---|---|---|---|---|
| Low back pain | Caused by lumbar lordosis; shift in centre of gravity and ligament laxity | Previous low back pain; previous pregnancy conditions causing large abdomen | Low posterior pelvic pain, relieved by lying or sitting | Early education; early training |
| Transient osteoporosis (TO) and avascular necrosis of the hip (AVN) | Rare conditions; aetiology unknown | Hip pain at rest; pain on movement; pain on weight-bearing; sometimes night pain | Limited movement of hip; MRI, pelvic ultrasound and radiograph | TO – No action required, self-limiting AVN – need early orthopaedic referral |
Compression neuro/ tendinopathies
| Both caused by increased fluid retention | CTS – Pain, numbness tingling over lateral three and a half fingers DT – pain on radial side of hand | CTS – Tinel’s test, Phalen’s test ultrasound DT – tenderness near radial Styloid; Finkelstein’s test | Mild conditions do not require any intervention Identifying the condition, observing the progression and reassurance are important initially |
Cauda Equina Syndrome
Key Facts
Rare complication; seen 1 in 10 000 pregnancies [3].
However, when diagnosed it is an emergency that requires an acute surgical intervention.
This is caused by lumbar disc herniation compressing the cauda equina.
Key Implications
Key Pointers
Pre-existing lumbar disc disease
Pregnancy-related changes (see earlier)
Increased maternal age [4]
Key Diagnostic Signs
Acute onset or progressively increasing back ache
Pain spreading down the legs
Motor involvement; muscle weakness mainly at L4, L5, S1 roots
Lower limb motor weakness (L4, L5, S1)
Foot drop
Bladder sphincter involvement causing either urinary retention or incontinence
Bowel involvement; mainly loss of anal sphincter tone
Key Actions
Once clinical diagnosis is made.
If cauda equina is suspected it should be referred to the spinal team urgently (prthopaedic or neurosurgery depending on the hospital), as early surgery gives the best results.
In pregnancy clinical features can be easily missed; therefore a high index of suspicion is needed make a diagnosis.
Early diagnosis.
Early referral.
Management in a Low-Resource Setting
MRI scans can be omitted, as the diagnosis is mainly clinical. However, when surgery is indicated an MRI scan is taken, as it allows localisation of the lesion and act as a road map for the surgeon. If MRI is not available a CT scan is an option. However, it is worth noting that CT exposes the patient to radiation and has a limited value in showing soft tissues.
Key Actions/Management
Lower back pain and lumber disc herniation do not need an acute surgical intervention, as they are self =-limiting and likely to resolve after delivery.
Symphysis Pubis Diastasis
Key Facts
Pubic symphysis separation is a recognised complication of pregnancy, with incidence estimates ranging from 1 in 600 to 1 in 3400 among obstetrics patients [5].
Most cases are self-limiting and resolve spontaneously during the postpartum period and do not require any acute intervention.
Most patients respond to conservative management (Figure 30.1). However, severe disruptions, persistent symptoms and unstable symphysis pubis diastasis will require surgical intervention.
Figure 30.1 Supporting the pelvic girdle in pregnancy.
Key Implications
Symphysis pubis diastasis itself in most cases is self-limiting and does not require surgical intervention. With conservative management most patients recover fully. However, it is important to identify patients who may need surgery, those with the following conditions:
Skeletal: associated damage to rest of pelvis ring sacra-iliac joints
Soft tissue:
1. Bladder injuries, bladder herniation [6]
2. Vaginal injuries (rare)
3. Rectal injuries (rare)
Key Pointers
Key Diagnostic Signs
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