971 - Minimizing fetal risks to radiation exposure during a fluoroscopic-guided cervical interlaminar epidural injection in a pregnant patient

Case Diagnosis: C5-C7 left foraminal disc extrusions with spinal canal and neuroforaminal stenosis.

Case Description: A 39-year-old female was evaluated at 22 weeks gestation for progressive radicular neck pain and left arm numbness acutely worsening over several weeks. The sharp pain radiates  from her neck into her chest, trapezius, and scapula severely limiting her ADLs. MRI confirmed C5-C7 left foraminal disc herniations, correlating with her radiculopathy. She is scheduled for spinal surgery with orthopedics following her pregnancy.

Discussions: Before spinal interventions, conservative management for radicular pain should be attempted, with this patient’s pain persisting despite OTC pain relievers, physical therapy, and home exercises. Her severe pain is managed by a multidisciplinary team—her OB/GYN, orthopedist, and PM&R.
The risks of in-utero radiation: prenatal death, growth retardation, organ malformation, and intellectual disabilities, highlights the need for meticulous planning. Strategies to mitigate radiation exposure were prioritized for this procedure, starting with the intervention performed during the third trimester of pregnancy, given increased fetal risks during the first trimester. Protective measures included: a lead vest and skirt to shield the patient and neonate, with two additional lead vests—one on the patient and the other on the procedure table. Limited pulsed fluoroscopy was done to minimize time of radiation exposure. Emotional/spiritual support addressed concerns about fetal safety, including offloading abdominal pressure with supportive pillows

Conclusions: The decision to perform epidural injections during pregnancy requires balancing the risks of fluoroscopic radiation with potential benefits/symptomatic relief. Despite initial hesitancy to perform an epidural injection, the procedure was deemed necessary given severe pain and quality of life concerns. Limited data on fluoroscopic-guided procedures in pregnancy highlights the need for research on mitigation techniques, including radiation times, exposure amounts, and variations in imaging and epidural techniques. This case underscores the need for further studies on minimizing radiation exposure to pregnant patients requiring spinal intervention