Backache is not a trivial symptom. It is one of the commonest causes of time off work in the UK, and can be particularly debilitating for the nursing mother.
Backache is very common, and a high proportion of women have significant backache before pregnancy, with surveys putting this figure at around 15%. During pregnancy, the prevalence of backache rises to ~50%.
Long-term backache after childbirth (defined as backache lasting longer than 3 months) occurs in about a third of women, and this increases to half if there is a history of backache before or during the pregnancy. The incidence of new, long-term backache in women with no symptoms of backache before or during pregnancy is much lower, at around 5-10%.
Problems and special considerations
Prospective studies have found no significant increase in the risk of backache when epidural analgesia is used in labour, nor an association with motor block. Despite this, there is a popular belief among parturients, midwives and even obstetricians that there is a causative link between epidural analgesia in labour and subsequent backache, largely arising from retrospective surveys of mothers in the late 1980s. Many women who develop intractable backache shortly after an anaesthetist has inserted a needle into their back will, not surprisingly, believe that the two are connected, and commonly refer to their backache as starting ‘after the epidural’ instead of ‘after the baby’.
This is not to say, of course, that a poorly administered epidural cannot cause trauma that might lead to backache, or that backache should be ignored after an epidural. In particular, acute tenderness over the epidural site should always raise the suspicion of an epidural abscess or haematoma, especially when accompanied by pyrexia and signs of nerve root irritation or cauda equina syndrome. Finally, rare coincidental causes such as a tumour should not be overlooked.
Management options
Women with backache often present to the anaesthetist in the antenatal period. Referral to the obstetric physiotherapist, lumbar support, simple analgesia and transcutaneous electrical nerve stimulation (TENS) may all be of help.
While the evidence does not support a causal link between epidural/spinal analgesia/ anaesthesia and long-term backache, many women ask about this complication, especially at antenatal classes, and the best approach is to inform them of the high risk of backache associated with pregnancy and childbirth, and to reassure them that these techniques do not appear to increase this risk.
The woman who presents with severe backache or a long history of back trouble in the antenatal clinic should be warned that it is very likely that this will continue after childbirth. Epidural analgesia should not be contraindicated in these cases, but it may sometimes be more painful having an epidural sited in a sensitive back. Care should be taken to avoid unnatural postures that will unduly stress the ligaments, and the patient should be allowed to move freely in labour. Support of lumbar lordosis and prevention of hyperextension at the hips are helpful.
Midwives should be alerted to refer severe, acute, localised backache after epidural insertion to the anaesthetist. Management should include a full neurological examination, and a low threshold for early referral to a neurologist and imaging to exclude haematoma or abscess formation.
Localised tenderness and limitation of movement may be due to a small haematoma in the interspinous ligament or paraspinous muscles, and these will often respond to physiotherapy.
Key points
• Backache is very common after childbirth.
• There is no apparent link between epidural/spinal analgesia/anaesthesia and long-term postpartum backache.
• Tenderness associated with pyrexia should raise the suspicion of abscess.
Further reading
Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev 2018; (5): CD000331.
Han IH. Pregnancy and spinal problems. Curr Opin Obstet Gynecol 2010; 22: 477-81.
Orlikowski CE, Dickinson JE, Paech MJ, et al. Intrapartum analgesia and its association with post-partum back pain and headache in nulliparous women. Aust N Z J Obstet Gynaecol 2006; 46: 395-401.