Lumbar microdiscectomy during first trimester of pregnancy: Surgical, anesthetic, and radiation considerations with review of reported cases

Abstract

Background:

Lumbar disc herniation requiring surgical intervention during pregnancy is rare, particularly during the first trimester. Here, we highlight the pros and cons of performing a microdiscectomy (MD) during the first trimester for a pregnant 27-year-old female.

Case Description:

A 27-year-old pregnant female in her first trimester presented with a progressive right foot drop secondary to an L5–S1 disc herniation. After failing 6 weeks of conservative management, she underwent right L5–S1 MD under general anesthesia in the prone position. Maternal hemodynamic stability was maintained throughout the procedure, and fluoroscopy was limited to a single image. Postoperatively, motor strength improved with rehabilitation, and she subsequently delivered a healthy full-term infant without obstetric or neonatal complications.

Conclusion:

Medically and neurosurgically indicated lumbar MD should be appropriately performed in patients in their first trimester of pregnancy.

INTRODUCTION

Symptomatic lumbar disc herniations for patients in their first trimester of pregnancy may put their fetus at risk of radiation exposure and hemodynamic instability. Nevertheless, significant neurological deficits may warrant operative intervention. Here, a 27-year-old female successfully and safely (i.e., including to the fetus) underwent a L5–S1 microdiscectomy (MD) during her first trimester of pregnancy due to a progressive foot drop that had failed to respond to conservative therapy.

CASE REPORT

A 27-year-old female in her first trimester of pregnancy had failed 6 weeks of conservative therapy for her right-sided foot drop (3/5). When the lumbar magnetic resonance showed a large right-sided L5–S1 disc herniation compressing the L5 nerve root, she underwent a MD following neurosurgical/obstetric consultations [Figure 1]. Anesthesia was induced with propofol and cisatracurium and maintained with inhalational anesthesia. Fluoroscopy was limited to a single image for level confirmation. Following removal of the extruded calcified right L5–S1 disc fragment, the patient had an uneventful postoperative recovery. The obstetric team documented with postoperative ultrasound the safety/viability of the fetus. The foot drop improved to the 4+/5 level 6 weeks’ later, and she delivered a healthy full-term male at 39 weeks of gestation. Six months postpartum, the patient and her baby remained symptom-free.

Figure 1:

Preoperative magnetic resonance imaging (MRI) lumbosacral spine images. (a) MRI T2-weighted sagittal image showing a large disc prolapse at the L5-S1 level (white arrow). (b) MRI T2-weighted axial image showing significant compression of the exiting nerve root on the left side at the same level through the prolapsed disc fragment (white arrow).

DISCUSSION

MD during pregnancy is rarely reported [Table 1], and most published cases were performed during the second or third trimester.[10,11] Our patient underwent successful L5–S1 MD during the first trimester for a progressive motor deficit, adding to the limited literature on this condition. General anesthesia during the first trimester is often avoided because of concerns regarding fetal organogenesis. Commonly used anesthetic agents do not have teratogenic effect.[2] Anesthesia in our patient was induced with propofol and cisatracurium and maintained with inhalational anesthesia. Large observational studies suggest that adverse pregnancy outcomes following non-obstetric surgery are more likely related to the underlying maternal condition and perioperative physiological disturbances than to direct drug effects.[6] Although regional anesthesia has been described in selected lumbar procedures, it may produce sympathetic blockade and maternal hypotension, potentially compromising uteroplacental perfusion.[6]

Table 1:

Summary of published reports of first-trimester lumbar disc surgery cases.

Positioning during spine surgery is another major concern in pregnancy. In the first trimester, the uterus remained confined to the pelvis, making prone positioning feasible when abdominal compression is avoided.[3] Our patient was positioned using chest and pelvis bolsters that allowed the abdomen to hang freely, and no intraoperative hemodynamic instability occurred. In contrast, lateral or modified prone positioning may be preferable later in pregnancy when aortocaval compression becomes a greater concern.[3,4,12] Minimizing fetal radiation exposure is another important consideration during first-trimester spine surgery. In our patient, fluoroscopy was limited to a single C-arm image for level confirmation, resulting in fetal radiation exposure well below the accepted safety threshold. Deterministic fetal effects are associated with doses exceeding 100 mGy, whereas exposure below 50 mGy has not been linked to fetal anomalies, growth restrictions, or miscarriages.[14]

Careful multidisciplinary planning involving neurosurgery, obstetrics, and anesthesia, together with attention to anesthetic management, positioning, and radiation minimization, enabled successful maternal neurological recovery and a healthy term delivery. Given the rarity of first-trimester lumbar disc surgery, additional well-documented cases are needed to better inform future clinical decision-making.

CONCLUSION

Patients in their first trimester of pregnancy presenting with significant progressive neurological deficits from lumbar disc herniations, depending on clearance by their obstetric experts, may potentially safely undergo surgical decompression.

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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