Long-term epidural analgesia for pregnancy-induced intercostal neuralgia

Abstract

Intercostal neuralgia is one of many possible neurological disorders associated with pregnancy. A woman presented in the 34th week of her 4th pregnancy with progressing right-sided pain and hypoesthesia in the ribs, right upper quadrant of the abdomen, and mid-thoracic area of her back. With a clinical diagnosis of pregnancy-related intercostal neuralgia, we inserted an epidural catheter at T8 for ambulatory pain management. A continuous infusion of bupivacaine was titrated by concentration and rate until adequate analgesia was obtained. The final effective dose consisted of 0.125% bupivacaine at 6 ml/h with a patient-controlled bolus dose of 2 ml every 30 min as needed (4-6 boluses per 24-h period). This allowed the patient to continue to work full-time and perform daily activities with minimal discomfort. The epidural infusion was continued until the patient went into spontaneous labor 28 days after the initial clinical visit. A full-term infant was delivered without incident. No major complications occurred such as local anesthetic toxicity, hypotension, motor weakness, or infection. Minor complications included disconnection of the catheter cap and accidental dislodgment, which required placement of a second epidural catheter. For this patient, an appropriately placed chronic epidural catheter and a titrated continuous infusion of bupivacaine provided adequate and safe analgesia for pregnancy-associated intercostal neuralgia.

The management of nonobstetric pains in pregnancy

“…2 Altered sensation may be present in the area of innervation of 1 or more intercostal nerves and may persist postpartum. 3,4 However, as in the case we report, parturition is usually associated with a relief of symptoms as the uterus contracts and the neural stretching recedes. A recent case report advocated continuous epidural analgesia with bupivicaine 0.125% in the last 28 days of gestation with good results.…”

“…A recent case report advocated continuous epidural analgesia with bupivicaine 0.125% in the last 28 days of gestation with good results. 3 We could not find a previous report of treatment with intercostal nerve block. Other possible causes of upper abdominal pain in pregnancy are cholecystitis, duodenal ulceration, torsion, threatened abortion, premature labor, and pre-eclamptic pain.…”

Neuromuscular disorders in pregnancy

“…36 Epidural anesthesia may also provide relief until delivery. 111 Radial Neuropathy. Inappropriate use of a birthing bar during labor may lead to compression of the radial nerve at the level of the spiral groove.…”

“…Once intraabdominal pathology is excluded, neuropathic thoracic pain during pregnancy has varied causes, including spinal cord lesions, radiculopathy, and irritation of the nerve trunks. 111,116 Some women develop sensory changes in the distribution of a thoracic root or intercostal nerve. 95 EMG may localize fibrillation potentials or positive waves in thoracic paraspinal muscles.…”

Neuromuscular Diseases in Pregnancy

“…Intercostal neuralgia: Intercostal neuralgia usually manifests in the third trimester of pregnancy with radicular pain in the distribution of one or two thoracic nerve roots [29,30]. It has been attributed to mechanical stretching from the enlarging uterus [31].…”