P025: SCIATIC ENDOMETRIOSIS IN PREGNANCY: NEURAXIAL ANESTHETIC MANAGEMENT IN THE SETTING OF DIAGNOSTIC UNCERTAINTY
Justin Scuorzo, DO, MMS; Karina Oganezova, MD; Giselle Helo, MD, FASA; Marisol Perales, MD
Memorial Healthcare System
Background: Sciatic endometriosis is a rare manifestation of extrapelvic endometriosis involving the lumbosacral plexus or sciatic nerve, characterized by cyclic radicular pain and episodic lower extremity weakness.1 Deep infiltrating disease occurs in 1-2% of cases, and sciatic involvement represents < 0.1-0.5%, described primarily in case reports. Neural involvement may occur despite normal lumbar imaging, delaying diagnosis and complicating anesthetic risk assessment. Current guidelines from the American Society of Regional Anesthesia and Pain Medicine and the American Society of Anesthesiologists emphasize individualized assessment, baseline neurologic documentation, shared decision making, and risk mitigation when neuraxial techniques are considered in patients with preexisting neurologic symptoms. 2,3
Case Description: A 37-week G1P0 woman (BMI 29.2) presented for scheduled cesarean delivery after prior myomectomy. Since adolescence, she reported cyclic left sided sciatic pain progressing during menses to transient lower extremity weakness requiring assistive ambulation, with complete resolution between episodes. This pattern raised suspicion for hormonally mediated peripheral neural involvement. Neurologic evaluation, including lumbar MRI and lumbar puncture, were unrevealing. Nerve conduction studies were deferred due to the intermittent, self limited nature of symptoms.
After her prior myomectomy under general anesthesia, she experienced five days of postoperative gait impairment. Similarly, during pregnancy she reported transient lower extremity weakness following vaginal examination. Both episodes resolved without objective deficits, suggesting positional or fluctuating peripheral symptoms rather than central neuraxial injury. On presentation, neurologic examination was normal and updated imaging excluded central pathology.
Given diagnostic ambiguity and concern for potential exacerbation of suspected peripheral sciatic disease, epidural anesthesia was selected to allow incremental dosing, titratable sympathectomy, and close hemodynamic control. Baseline neurologic status was documented preoperatively. Informed consent addressed diagnostic uncertainty and the possibility of symptom recurrence independent of anesthetic technique. Intraoperative management emphasized maintenance of mean arterial pressure near baseline and neutral lower extremity positioning. Cesarean delivery was uncomplicated, and on postoperative day one she demonstrated no motor or sensory deficits.
Discussion: This case highlights a clinically challenging and underreported scenario. Although neuraxial anesthesia is standard for cesarean delivery, concern for worsening neurologic symptoms may prompt avoidance despite absence of central pathology. Diagnostic ambiguity increases the risk that postpartum neurologic symptoms could be misattributed to anesthetic technique rather than underlying disease or positioning.
Management should be structured and deliberate. Clinicians must differentiate peripheral from central pathology and exclude compressive or demyelinating disease. 2,3 A detailed baseline neurologic examination should guide postoperative assessment. Shared decision making is essential, acknowledging uncertainty and potential symptom recurrence independent of anesthetic choice.
Unlike patients with established central demyelinating disorders, this patient exhibited intermittent peripheral symptoms without radiographic evidence of central nervous system involvement. The decision to proceed with epidural anesthesia was therefore guided not by concern for demyelinating vulnerability, but by the advantages of incremental dosing, controlled hemodynamics, and early detection of atypical neurologic changes in the setting of diagnostic uncertainty.
References:
1. https://doi.org/10.3171/2010.10.SPINE09162