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Interscapular Pain: A Case Series
Abstract Number: T-74
Abstract Type: Case Report/Case Series
Some laboring women experience severe upper back pain, typically between the scapulae, after initiation of neuraxial labor analgesia. The etiology of this interscapular pain (ISP) is not well understood, but theories include high epidural space pressures (1), compression of the thoracic spinal cord (2), referred pain from abdominal viscera (3), or air in the epidural space (4). Management options include decreasing the epidural infusion rate, administering epidural or intravenous opioids, and withdrawal or removal of the epidural catheter (5). This case series describes three patients who developed ISP during labor.
An 18 year old (y.o.), G1P0, with BMI 32 and gestational hypertension presented in labor at 37.1 weeks. She requested analgesia at 2.5 cm cervical dilation. Labor analgesia was initiated using a combined spinal-epidural (CSE) technique and maintained using patient-controlled epidural analgesia (PCEA) with an 8 mL/hr continuous infusion. She required three physician-delivered boluses for treatment of breakthrough pain. She received a total of 312 mL epidural local anesthetic. After 19 hrs of labor, she proceeded to cesarean delivery for arrest of dilation. Intense ISP developed during bolus administration of lidocaine 2% with epinephrine. Epidural fentanyl (100mcg) provided some relief; however, due to an inadequate sensory level (T7), the decision was made to replace the epidural catheter. She experienced complete ISP relief upon epidural replacement.
A healthy 33 y.o. G2P1 with BMI 31 presented for induction of labor at 37.0 weeks. A CSE was requested at 1cm dilation, and a PCEA initiated. She developed moderate ISP and lower neck pain six hrs later. She had received 120 mL of epidural local anesthetic. Her pain decreased when sitting up in bed. She had similar pain with a prior labor epidural. Her PCEA infusion rate was decreased from 8 to 6 mL/hr and the bupivacaine concentration was increased from 0.0625% to 0.11%. Her pain resolved after 1 hr. Uncomplicated NSVD followed.
A healthy 27 y.o. G3P0 with BMI 29 presented in labor at 40.1 weeks. A CSE was requested at 0cm dilation and a PCEA was initiated. The patient developed severe ISP 9.5 hrs later that worsened with PCEA demand bolus. She had received 116 mL of epidural local anesthetic. Her epidural bupivacaine concentration was increased from 0.0625% to 0.11%. Epidural fentanyl 100mcg was also administered. The patient experienced complete pain relief 1.5 hrs later. Uncomplicated NSVD followed.
This case series presents 3 parturients with ISP. All patients received relief with administration of epidural fentanyl, reducing the rate of the epidural infusion, or replacement of the epidural catheter. Future work should characterize at risk-patients, as well as delineate effective treatment options.
1. IJOA 2011; 20: 196
2. IJOA 1993; 2: 190-2
3. IJOA 2010; 19: 463-4
4. Anaesthesia 1989; 44:1014
5. Anesthesiology 2007; 107: A1780