Anaesthetic management

Women with pre-existing musculoskeletal pathology should be fully assessed during the antenatal period. Previous spinal surgery is not a contraindication to regional analgesia and anaesthesia, although many women may have been told by their midwife, general practitioner or orthopaedic surgeon that they will be unable to have epidural analgesia. There may be respiratory impairment following significant corrective surgery, and some postoperative neurological deficit, and if so these must be documented antenatally. Women should be told that epidural analgesia for labour does not increase the likelihood of experiencing postnatal backache.

There is no contraindication to vaginal delivery nor to the use of regional analgesia in women with pregnancy-related back pain, although many women request (and some obstetricians suggest) delivery by elective Caesarean section to avoid any risk of exacerbating existing back symptoms.

Previous hospital records are helpful, since the position of the scar on the woman's back is not a reliable guide to the level of surgery. Most women will know whether they have had metal instrumentation of the spine or merely bony fusion. Those who have had instrumentation should be warned about possible technical difficulties in correctly positioning an epidural needle; it may be easier to perform spinal anaesthesia or analgesia. If successful epidural catheterisation is achieved, it may be difficult to obtain reliable spread of local anaesthetic, and this should be explained before starting the procedure.

Regional anaesthesia and analgesia in women who have had discectomy or laminectomy is not usually technically difficult, but there may be a slightly increased risk of inadvertent dural puncture, and patients should be warned about this.

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