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Marinho, P. Frias, I. Oliveira, R. Silva, F. Rodrigues, A. Paiva" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Marinho" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Frias" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Oliveira" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Silva" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "A." 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "215" "paginaFinal" => "218" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "N. Fuertes Sáez, I. Giménez Jiménez, M. Batista Doménech, F. Montero Sánchez, I. Elia Martínez, P. Argente Navarro" "autores" => array:6 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Fuertes Sáez" "email" => array:1 [ 0 => "Neusfuer@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Giménez Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Batista Doménech" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Montero Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Elia Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "P." "apellidos" => "Argente Navarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Déficit motor en el puerperio. ¿Es la analgesia neuroaxial la causa más frecuente?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 688 "Ancho" => 800 "Tamanyo" => 57625 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">MRI image of the hips. Arrow: joint effusion. Star: left hip bone oedema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lower limb motor deficits are relatively frequent during pregnancy and the puerperium, and are sometimes associated with low back pain. Since neuraxial techniques are usually used for analgesia during labour or caesarean section, motor deficits in the puerperium are initially assessed by an anaesthesiologist.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the event of sudden onset of motor deficit after neuraxial anaesthesia, it is a essential to first perform lumbar magnetic resonance imaging (MRI) to rule out the presence of spinal haematoma, and if found, to treat it immediately.</p><p id="par0015" class="elsevierStylePara elsevierViewall">These neurological symptoms can also be associated with other pathologies, such as lumbar plexus neuropathy during the expulsion stage, or more infrequently, hip osteopenia. Symptoms of the latter usually begin in the third trimester of pregnancy and sometimes occur before or during the postpartum. It is a self-limiting pathology of unknown aetiology.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Accurate differential diagnosis should be performed as soon as the warning signs (motor deficit) appear, particularly if the patient has received neuraxial anaesthesia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 35-year-old full-term pregnant woman (40<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 weeks) with no history of interest was admitted due to premature rupture of the membranes. The patient went into labour and requested epidural analgesia. Coagulation tests were normal, so an epidural catheter was successfully placed after a single puncture. After 12<span class="elsevierStyleHsp" style=""></span>h, caesarean section was indicated due to lack of progress, so 10<span class="elsevierStyleHsp" style=""></span>ml 2% lidocaine was administered via the epidural. After confirming sensory and motor blockade at the level of T4, the caesarean section was performed without incident, and the epidural catheter was withdrawn. The patient was discharged to the ward 2<span class="elsevierStyleHsp" style=""></span>h later.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At 48<span class="elsevierStyleHsp" style=""></span>h after the caesarean section, the patient started to present motor deficit in the left leg, with difficulty walking, inability to perform flexion and extension while standing, and pain when moving the left hip. No sensory deficit was detected. The patient was evaluated by the anaesthesiology team and the Neurology service; urgent lumbar and hip MRI was initially requested, and later extended due to inconsistencies in the neurology examination that suggested syringomyelia at the level of D6.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The MRI showed extensive bone oedema in the left femoral head and femoral neck, with reactive joint effusion, and a small subchondral oedema in the right femoral head (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The spinal MRI was unremarkable (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A diagnosis of transient osteoporosis of the hip was given and spinal cord involvement was ruled out.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">After these findings, the patient was evaluated by Orthopaedics and conservative treatment with rest and analgesia followed by rehabilitation was ordered.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was re-evaluated 5 days later and showed frank improvement, being able to walk with support. She reported less pain on movement and loading of the lower left limb, and was discharged home with follow-up at 2 months in a specialised centre.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Transient osteoporosis of the hip usually occurs in the third trimester of pregnancy, and is characterised by progressive pain at the level of the groin or greater trochanter that radiates to the anterior thigh. It is associated with difficulty walking, but not with sensory deficits.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Symptoms are aggravated by joint loading and alleviated with rest.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It is usually self-limiting, but can lead to serious complications, such as pathological fracture of weight-bearing joint. It usually occurs in the left hip, but cases involving the right or both hips have been described, as in this case.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence is difficult to assess due to the difficulty in diagnosis, which is always based on imaging tests. Initial radiographs may be normal because the typical signs of diffuse osteoporosis of the femoral head and neck alterations usually appear between 3 and 8 weeks after the start of symptoms.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> A bone scan shows increased tracer uptake in the cup and femur at an early stage.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The diagnostic technique of choice is MRI. Characteristic changes include decreased bone marrow signal intensity on T1-weighted images and increased signal intensity on T2, as well as a small joint effusion.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The pathogenesis involves various factors: trabecular microfractures due to a decrease in bone mass in pregnancy, circulatory disorders, or compression of the obturator nerve or the pelvic portion of the sympathetic trunk due to the weight of the uterus.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">During pregnancy, particularly during the third trimester, calcium metabolism is altered to deliver calcium to the foetus. The increase in parathyroid hormone levels could explain the loss of bone mass that underlies osteoporosis of pregnancy. Furthermore, existing bone fragility can contribute to the development of this pathology.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">As far as treatment is concerned, rest to avoid joint loading, analgesics, and rehabilitation are recommended.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Transient osteoporosis of the hip must be considered in all pregnant women in the third trimester or in postpartum women with no history of trauma who present the symptoms described.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It is important to bear this entity in mind in order arrive at the correct differential diagnosis and rule out pathologies that require immediate treatment. Diagnosis will also help obtain a reliable estimate of its prevalence.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Pregnant woman with osteopenia of the hips who have received neuraxial anaesthesia must be warned to take care when moving, since the anaesthesia will dull the pain and increase the risk of fracture.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The symptoms to be taken into account during differential diagnosis include:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Hip-related problems: osteonecrosis, inflammatory rheumatism, infection, metabolic disease, synovial disease, neoplasm, osteomalacia and injury.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Lumbar, sacroiliac, pubic symphysis, urogenital and digestive disorders.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">It is also important to rule out pelvic joint disorders associated with assisted or excessively prolonged deliveries that lead to malpositions. Injury to the pudendal nerve during childbirth (or episiotomy) can also cause symptoms of pain radiating to the lower limbs and paresthesia.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Problems related to the neuraxial technique should be ruled out. Any delay in diagnosis could be catastrophic and cause permanent sequelae, including: spinal haematoma, epidural abscess, direct spinal injury, and neurotoxicity induced by local anaesthetics. Of these, epidural-induced spinal haematoma is the most common complication, with an incidence that varies widely from 1:200,000 in obstetric patients and 1:22,000 in elderly women undergoing orthopaedic surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The risk of neuraxial injury increases in patients with coagulation disorders, when multiple attempts are needed to perform neuraxial anaesthesia, in the elderly, and in female patients. Pre-existing spinal stenosis, vertebral canal pathologies or neurological disorders can aggravate the severity of the injury.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">It is essential to include osteoporosis of the hip in the differential diagnosis in all pregnant women with symptoms of groin pain and lower limb motor deficit, and to perform imaging studies (preferably MRI) as soon as possible to both confirm the diagnosis and rule out pathologies whose symptoms may be masked and that require urgent intervention, such as epidural haematoma.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion, complications after neuraxial techniques may be the cause of a neurological deficit, and it is important to rule them out, bearing in mind other pathologies that produce similar symptoms and require differential diagnosis. That is why the anaesthesiologists play a pivotal role in the initial evaluation of these cases.</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is essential to know which pathologies should be included in the differential diagnosis of patients presenting neurological deficit during pregnancy and/or the puerperium in order to make an early diagnosis and take the appropriate measures.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1330898" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1226245" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1330899" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1226244" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-05" "fechaAceptado" => "2019-10-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1226245" "palabras" => array:4 [ 0 => "Motor deficit" 1 => "Hip osteopenia" 2 => "Puerperium" 3 => "Neuraxial anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1226244" "palabras" => array:4 [ 0 => "Déficit motor" 1 => "Osteopenia de caderas" 2 => "Puerperio" 3 => "Anestesia neuroaxial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Motor deficits of lower limbs during pregnancy and the puerperium are relatively frequent. They are usually attributed to complications which are associated with neuraxial techniques performed by the anaesthesiologist. But there are other possible causes, such as transient osteoporosis of the hips.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transient osteoporosis of pregnancy is a rare and self-limited pathology of unknown aetiology. The most severe complication that can occur are pathological fractures, mainly in the load joints. This pathology usually occurs in the third trimester of pregnancy and is showed up with pain and functional impotence of the lower limb affected.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We present the case of a 35-year-old woman, 40<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 weeks of pregnancy who starts labour. Normally functioning epidural catheter is placed and finally caesarean section is decided because failure to progress; 48<span class="elsevierStyleHsp" style=""></span>h later the patient begins with functional impotence and pain in the lower left limb. MRI is performed, epidural haematoma is ruled out and osteopenia of the hips is proved. The patient is diagnosed with transient osteoporosis of pregnancy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los déficits motores de miembros inferiores durante el embarazo y el puerperio son relativamente frecuentes. Se atribuyen habitualmente a complicaciones asociadas a las técnicas neuroaxiales que son realizadas por el anestesiólogo. Pero existen otras posibles causas, como la osteoporosis transitoria de caderas.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La osteoporosis transitoria del embarazo es una patología infrecuente y autolimitada de origen desconocido. La complicación más severa que puede presentar son las fracturas patológicas, fundamentalmente en las articulaciones de carga. Esta patología suele presentarse en el tercer trimestre del embarazo y cursa con dolor e impotencia funcional del miembro inferior afecto.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una mujer de 35 años, gestante de 40<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 semanas que inicia trabajo de parto. Se coloca catéter epidural normofuncionante y finalmente se decide cesárea por parto estacionado; 48<span class="elsevierStyleHsp" style=""></span>h después comienza con impotencia funcional en miembro inferior izquierdo y dolor. Se realiza RM donde se descarta haematoma epidural y se objetiva osteopenia de caderas, siendo diagnosticada de osteoporosis transitoria el embarazo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fuertes Sáez N, Giménez Jiménez I, Batista Doménech M, Montero Sánchez F, Elia Martínez I, Argente Navarro P. Déficit motor en el puerperio. ¿Es la analgesia neuroaxial la causa más frecuente? Rev Esp Anestesiol Reanim. 2020;67:215–218.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 688 "Ancho" => 800 "Tamanyo" => 57625 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">MRI image of the hips. Arrow: joint effusion. Star: left hip bone oedema.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 695 "Ancho" => 800 "Tamanyo" => 55500 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">MRI image of the spine showing no sign of spinal cord compression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transient osteoporosis of pregnancy: a case report and review of anesthetic implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.E. Lombana" 1 => "E. 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