Back Problems and an Epidural: Can You Still Have One?

Most back problems do not take an epidural off the table. Scoliosis, a herniated disc, sciatica, earlier spine surgery and chronic back pain are things obstetric anesthesia teams plan around. The American College of Obstetricians and Gynecologists (ACOG) lists previous spinal surgery among the conditions that can affect your pain relief options, and says you may be scheduled to meet with an anesthesiologist before labor or when you arrive at the hospital. What usually changes is the plan rather than the answer: your team may want to see imaging, talk through your anatomy and be ready for a placement that takes a little longer.

If you've been quietly worried that your back history will mean a labor without an epidural, the picture is usually more flexible than you might expect.

#The Short Version

A few things to anchor on:

• Most back conditions, including most cases of scoliosis, still allow an epidural.
• A back history can make placement more technically challenging, which is different from impossible.
• Earlier surgery, especially a fusion with hardware, is the situation most likely to change the plan.
• Telling your team early, ideally before labor, gives them time to plan around your anatomy.
• The best randomized evidence does not link an epidural to long-term back pain.

The right frame is "let's plan around your anatomy" rather than "let's see if you qualify."

#Can You Get an Epidural With a Herniated Disc or Sciatica?

In many cases, yes. A Mayo Clinic study of 937 patients with spinal stenosis or lumbar radiculopathy, the pinched-nerve pain that includes sciatica, found that the spinal or epidural worked in 97.2% of them. The same study found that about 1 in 100 had new or worse nerve symptoms afterward, and the authors could not tell whether the surgery, the anesthetic or the underlying condition was the cause, which is one more reason your team asks about your current symptoms. Those patients were having surgery rather than giving birth, so the number doesn't carry over exactly to labor, but it's reassuring on the basic question of whether a disc problem rules out the technique.

What your team will want to know is how your symptoms are right now. A review of spinal and epidural techniques in patients with existing back problems calls for a careful exam beforehand so the team knows your current status, and advises avoiding high concentrations and volumes of numbing medicine in patients with nerve compression or a large disc herniation. So if you have numbness, weakness or leg pain today, mention it, even if it feels unrelated to labor. Having your baseline written down helps everyone tell later what was already there.

#Can You Get an Epidural With Scoliosis or Harrington Rods?

Usually, yes, though a curve or hardware can make placement more of a puzzle. A review of published reports on moms with scoliosis pulled together 117 attempted spinals and epidurals. Of these, 79% of moms with uncorrected scoliosis and 69% of moms with surgically corrected scoliosis were managed successfully with one. Procedures tended to be more challenging after surgical correction, and in that group 90% of the reported difficulties involved epidurals.

If you had a fusion with rods, including older Harrington rods, you're in the corrected group these studies describe. A later case-matched study of 41 moms with spinal instrumentation for scoliosis notes that early studies were small (9 to 21 patients) and reported success in only 50% to 66%, and that newer surgical techniques make the epidural space more accessible. In that study:

• Moms with instrumentation used about the same amount of numbing medicine per hour as moms without back surgery.
• Placement took about 41% longer on average and needed more needle redirections and more attempted levels.
• Labor pain relief from the spinal or epidural failed in 5 of the 41 moms (12%), compared with none in the comparison group.

The authors still concluded that an epidural should be offered, with an honest conversation beforehand about possible technical difficulty. For more on curves, fusion levels and planning, see the full article on scoliosis and epidurals.

#What If You've Had Back Surgery Before?

Earlier surgery doesn't automatically rule out an epidural. In the Mayo Clinic study, 207 patients had already had spine surgery, and that history did not affect the success rate or how often technical problems came up. Again, those patients were having surgery rather than labor.

Surgery can still change how an epidural behaves. The case-matched scoliosis study notes that changes after surgery may alter how well labor pain relief works, and the review of pregnant patients with congenital spine differences makes a similar point about earlier surgery for those conditions, noting that it may impair the spread of the numbing medicine. When medicine spreads unevenly, relief can feel patchy or stronger on one side, something the OAA's common questions page explains in plain terms. Your team has standard ways to respond. The Obstetric Anaesthetists' Association's patient information lists giving more medicine, changing your position, moving the catheter to a different place in your back, or suggesting a different type of anesthetic. For labor epidurals in general, the same page reports that about 5 in 100 need the catheter re-sited.

A fusion with hardware is the situation most likely to change the plan, so the details of your surgery matter. A report that shows which levels were operated on, and whether rods or screws were placed, helps the team decide where to aim. The back-problems review also notes that ultrasound may help raise the success rate.

#What About Spina Bifida Occulta?

If you've been told you have spina bifida occulta, it's worth knowing how common it is. According to the review of spine differences in pregnancy, the bony form, where part of a vertebra didn't fully close but the nerves are normal, occurs in up to 50% of the population, and 90% of those cases are confined to the sacrum, the bony base of the spine.

Other congenital spine findings can matter more. The same review explains that the concern with these is a spinal cord that sits lower than usual or is tethered, and it recommends an assessment before labor and an MRI to clarify the anatomy and identify the levels where a spinal or epidural can be placed. You don't need to work out which category you're in. Tell your team what you've been told, bring any imaging report you have, and let them decide whether anything more is needed.

#Should You Mention Recent Epidural Steroid Injections or Other Spine Procedures?

Yes. Some moms with back pain in pregnancy are treated with steroid injections, and a systematic review of low back pain in pregnancy lists injections into the epidural space or sacroiliac joints among the options that may help with pain. The back-problems review covers earlier spine interventions ranging from minor ones, like an epidural blood patch, to major fusion surgery, and describes the current evidence on spinals and epidurals in these patients as mostly reassuring. It also stresses a careful exam beforehand and an honest conversation about your condition. Telling your team what was done, where on your back and when lets them factor it in rather than find out in the labor room.

#When Is a Spinal or Combined Spinal-Epidural Used Instead?

Your team has more than one option. As ACOG explains, a spinal block is a single shot of medicine into the fluid around the spinal cord, given with a much thinner needle. It starts working quickly but lasts only an hour or two, and it's commonly used for cesarean birth. A combined spinal-epidural (CSE) gives the spinal first for fast relief, then places an epidural catheter for continuous relief.

For moms with back problems, the type of technique can matter. The back-problems review suggests that many of these patients may do better with spinal techniques than with epidurals, which it describes as less reliable, and the scoliosis review found most reported difficulties after surgical correction involved epidurals. So your team may suggest a spinal or a CSE, especially for a planned cesarean.

Sometimes a spinal or epidural isn't the right choice, and sometimes it simply needs extra planning. ACOG lists heart disease, certain blood disorders, liver disease and previous spinal surgery as conditions that can affect your pain relief options, which is different from ruling them out, and the spine-differences review explains why a low-lying or tethered spinal cord calls for careful planning. Even then, there are other ways to ease labor pain. ACOG describes opioid pain medicine given through an IV or as a shot, and nitrous oxide, which some hospitals offer, and notes that general anesthesia is usually used only for emergencies during childbirth. Knowing this ahead of time is part of why an early conversation helps.

#Should You See an Anesthesiologist Before Labor?

Some back-related situations particularly benefit from talking with an obstetric anesthesiologist before labor:

• Significant scoliosis, or scoliosis that was surgically corrected
• Earlier lumbar surgery, a fusion or spinal hardware
• More than one spine surgery
• Any spine procedure or injection, such as an epidural steroid injection or a blood patch, especially a recent one
• A congenital spine finding, such as a tethered or low-lying cord, or spina bifida occulta that a doctor said needs a closer look
• New or worsening back pain, numbness or weakness during pregnancy

The consult typically involves reviewing your history, looking at any imaging you have, a focused exam and a documented plan that the on-call anesthesia team can see when you arrive in labor. Here's more on what a prenatal anesthesia consult looks like.

To make the most of it, bring what you can:

• Reports from any spine MRI, CT or X-ray
• Your surgical report, including which levels were operated on and any hardware
• A list of injections or other spine procedures, with dates
• A short note on your current symptoms, including any numbness, weakness or leg pain
• Anything you remember about earlier epidurals or spinals, such as one that didn't work well

If an earlier epidural worked on one side more than the other, the OAA suggests telling your anesthetist next time so they can plan ahead.

You don't need a consult for the occasional twinge of back pain in pregnancy or a long-resolved, minor episode in the past. A good threshold is "is there something specific the anesthesia team would benefit from knowing in advance?"

#Will an Epidural Make My Existing Back Pain Worse?

This is often the biggest worry for moms who already live with back pain. Here is what the evidence shows.

The strongest study is a randomized trial published in the BMJ that assigned 369 women to an epidural or to other forms of pain relief in labor and followed up 306 of them an average of 26 months after birth. There were no differences in the onset or duration of low back pain, in disability or in how well the spine moved. Nearly a third of women in each group reported back pain in the week before their interview, whether or not they'd had an epidural. The American Society of Anesthesiologists adds that soreness where the needle went in should last no more than a few days, and that there's no evidence an epidural can cause permanent back pain. More on this in the separate article on the back-pain myth.

The honest gap is that these studies weren't designed around moms who already had back problems. A systematic review of low back pain in pregnancy found only 4 studies on spinals and epidurals in this group and called the evidence limited. It also noted a potential for a higher risk of nerve complications in moms who already have neurological deficits, such as existing numbness or weakness. That's the reason your team asks about current symptoms, and why describing them clearly is useful.

Back pain after birth is common either way, as the BMJ trial shows. If your back is noticeably worse after delivery, other postpartum factors, like lifting and feeding positions, are common reasons, and a conversation with whoever treats your back is usually a good next step. If soreness where the needle went in lasts longer than a few days, or you notice new numbness or weakness in your legs, trouble controlling your bladder or bowels, or back pain with a fever, tell your care team right away.

#The Reframe

Back problems are common in pregnancy, and the teams who place labor epidurals plan around them routinely. Specific conditions may change the approach, the type of technique or the imaging your team wants to see, but for most moms the answer to "can I still have an epidural?" is yes, with a plan.

If your back history is more than a minor one, ask your OB about a prenatal anesthesia consult. It's not over-cautious. It's the kind of advance planning that lets the labor room conversation go smoothly while you're focused on labor itself.