a case of intolerable leg pain in pregnancy , caused by chronic compartment syndrome ( ccs ) , is presented .
in spite of numerous reports on leg cramps during pregnancy which usually cease after birth , an explanation to its cause or a scientifically based treatment for extreme cases has yet to be offered . in a postpartum study based on the return of a questionnaire from 78/120 women ,
cramps occurred mostly at night about twice a week , resulting in loss of sleep , reduced well - being , and work capacity .
patients were not questioned about possible leg cramps prior to the pregnancy . since the monography by renemann in 1968 , chronic compartment syndrome ( ccs ) of the legs has been associated with soldiers and sportsmen only .
recently a diagnostic protocol was published in which decision to operate ccs can be based upon clinical findings alone .
a 33-year - old woman with attention deficit / hyperactivity disorder , pregnant for the fifth time , had been treated for hypothyroidism until 2005 where after treatment seemed unnecessary .
she had also been operated for bilateral carpal tunnel syndrome with satisfactory result in 2003 .
prior to her fifth pregnancy , she had for many years suffered from leg pain which deteriorated at physical activity .
due to that pain she had been unable to tend to her caf - job for the last 2 years . in the presence of disturbing leg cramps occurring days and nights , a diagnostic pathway for ccs
was followed : the patient was seen by a neurologist , a specialist of physical medicine and rehabilitation and an orthopedic surgeon .
magnetic resonance imaging ( mri ) of the spinal canal and laboratory tests were performed together with the vascular status , pain drawing , a visual analogue scale ( vas ) pain score , and a health- related quality of life survey .
a specialist of rehabilitation medicine ( coauthor ) had suggested ccs of the legs as cause of her pain .
he noted that her leg pain had aggravated with menses and that a component of lumbar pain increased concomitantly .
she was therefore remitted to orthopedic examination and was seen by the first author on 30 august 2007 .
she stated that her leg pain , persistent for years , was similar to toothache and pinpricks , increasing to pressure and cramps with walking gradually more limited distances .
she was now unable to sleep continuously more than 3 h before having to get out of bed and walk to overcome leg cramps .
the first toe would always cramp into dorsiflexion , and although both her legs were painful , the right leg was worse than the left .
she made a pain drawing ( fig.1 ) and a vas pain score , commenting spontaneously that 120% pain was more like hers ( a patient with less than 50% vas pain score is usually not in need of surgery ) .
upon palpation of her legs , tenderness seemed excessive in all muscle compartments , perhaps maximal in the lateral compartments , increasing in all during an exertional step test .
arterial pulse was normal both in the groins , in the ankles , and in the feet .
the pain located above the knees might be considered as referred pain because it no longer existed postoperatively .
a lumbar computed tomography and mri showed completely normal findings . on examination of peripheral nerves in the legs , both before and after a step test , skin sensitivity was found to be reduced bilaterally in the areas of the nervus fibularis profundus , the nervus fibularis superficialis , and the nervus suralis while normal sensitivity was found in the dermatomes above knee level . her tentative diagnosis was bilateral ccs .
pressure measurements were postponed because they frequently led to increased pain for days . the decision on when to perform surgery
the attitude of the orthopedic department was one of expectancy : surgery could wait until the end of the first trimester or midway through the pregnancy as a caution toward unwanted medicament effects .
the patient stated that she did not want to go through with this pregnancy if she could not be relieved of her enormous leg pain . because the therapy in question was unfamiliar ,
instead , her general practitioner had to give her increasingly high doses of morphine , but with hardly any effect on her leg pains . nor
did she experience any effect from other tablets which were discontinued quickly . in detail , morphine in doses of 10 mg six times in 24 h was given in august 2007 with hardly any effect . from september 2007 until february 2008 she was treated with norspan plaster 5 g per hour , which was changed every week . during the same period she was given meperidine supp .
february 2008 , the date of decision to do an earlier caesarian section , an additional dose of 15 mg morphine had no effect . in view of her intractable pain ,
a caesarian section was planned for 10th march 2008 , but the date was expedited due to her pain which was unrelieved even by epidural anesthesia .
the spinal anesthesia did not either have the expected effect on her pain , and finally inhalation and intravenous medicaments were added .
she then gave birth to a boy with body weight 2880 g and apgar scores 91010 .
as morphine dose reduction started , she received support from an anesthesiologist and a psychiatrist .
she did not admit to any leg pain reduction after birth , but she agreed to go home to rest and gather strength before surgery .
she entered the hospital on 22 april 2008 when pressure measuring was performed ( table1 ) .
after the step test only one compartmental pressure was measured above 30 mmhg , but tenderness at palpation and skin sensitivity reduction in the forefoot indicated the need for fasciotomy in all four compartments . the next day , under general anesthesia , that surgical procedure was performed in the right leg .
that very evening the pain had disappeared in her right leg and the referred lumbar pain in the right side was markedly reduced . after three more months
the vas pain score in the right leg was down to 30% and she wanted and received identical surgery in her left leg on 30 july 2008 .
golden standard  for diagnosis of ccs has been measured pressures above 30 mmhg at follow - up after 2 years her legs were pain - free and the vas pain score in both had been reduced from 100% to 0% that is the best score possible .
she was able to walk , run or dance unlimited , she could sleep undisturbed by pain at nights , and she had begun to improve her social situation , blaming all her problems on the previous leg pains . a health - related quality of life survey ( hrql ) , sf-8 , providing information on physical , mental , and social dimensions of health , was markedly below normal scores before the operation , indicating severe impairments in hrql , while after the operation the score was normalized and even exceeded normal scores for women aged 3539 years ( table2 ) .
the patient 's sf-8 scores ( average ) before and after surgery and population norm scores for women aged 3539 years ( average  sd )
a 33-year - old woman was so disturbed by leg pain with cramps , lack of sleep , and tiredness that she wanted to terminate her fifth pregnancy unless she could be relieved of her pains . because ccs of the legs previously has not been reported as a cause of leg cramps , traditional relentlessness toward general anesthesia in the first trimester forced this patient to endure intractable pain until after she had given birth .
a literature search revealed that modern anesthetics no longer represent much of a risk to the fetus ( see below ) .
thus , a surgical solution could have been offered to this patient as soon as the diagnosis was obvious .
airway management can be impaired due to upper airway edema and vascular changes caused by the hormonal state .
studies have shown a 3.3% risk for difficult intubation and 0.4% risk for failed intubation during pregnancy .
there is also an increased risk for esophageal regurgitation and aspiration due to decreased esophageal sphincter tonus during pregnancy combined with difficult manageable airways .
in addition , the time to desaturate is decreased in the pregnant patient due to increased oxygen consumption and a decreased functional residual capacity .
van de welde et al . reviewed anesthesia to the pregnant patient and concluded that the drugs used today in general anesthesia are not considered to be teratogenic .
there are , however , several studies that link surgery during pregnancy with increased rate of spontaneous abortions , low - birth - weight and death within 168 h of live born infants .
the risks of hypovolemia and hypoxemia for the fetus are increased , however , due to the systematic hemodynamic effects such as vasodilatation and cardiac depression in the mother .
one study found the risk associated with general anesthesia during pregnancy to be a 17-fold increase in complications when compared to regional anesthesia .
the main concerns when performing surgery in regional anesthesia are hypotension and local anesthetic toxicity or anaphylaxis . the procedure can be handled in the same way as a caesarian section in regional anesthesia .
precautions should be undertaken , and appropriate vasopressors must be ready , to be prepared for hypotension and anaphylaxis as a result of injection of local anesthetics .
it is recommended to perform the surgery in the second trimester and elective surgery should be avoided .
the reported patient was given opioids ( morphine ) for pain relief during the pregnancy .
the norwegian drug information catalogue lists long - lasting morphine use during pregnancy as a possible agent for neonatal abstinence syndrome with symptoms as cramps , irritability , vomiting , and increased mortality .
the fda - approved box - labeling according to uptodate lists morphine as a class c drug (  risks can not be ruled out  ) during pregnancy . according to the warning
, morphine has not shown teratogenic effects in animal studies , but reduced growth and behavior abnormalities in offspring have been observed .
the frequency of congenital malformations has not been reported to be greater than expected in children from mothers treated with morphine during pregnancy .
the recommendation is to use minimal , if any , opioids during pregnancy in patients with chronic non cancer pain . the risk of analgesics for pain during pregnancy must be weighed against the risks associated with surgery during pregnancy .
she did not receive nonpharmacological treatment as iron replacement , mental training , leg stretching or elastic stockings . at this young age
, the presence of differential diagnoses like arteriosclerosis and venous insufficiency may be excluded by clinical examination only .
unspecific neuritis , polyneuritis , diabetic neuropathy , and spinal lesions must be excluded as well .
it might appear a paradox that normal results from electrophysiological examination are reported while changes of sensitivity are found .
pain as an isolated symptom , will usually only affect small and unmyelinated nerve fibers ( small fibers ) .
when the sense of touch is diminished , as is the case with our patient , you would expect an effect on myelinated fibers ( a - alpha ) .
the challenge is that a wide range of normal values for the standard parameter of nerve conduction exists .
our patient had symptoms from both lower extremities , if not we could have increased the sensitivity by comparing to the healthy side .
pain drawing has proven of value in discriminating a radicular pain caused by the l5-or s1-nerve roots from leg pain caused by ccs and possibly its referred pain to the trochanter and lumbar region , sometimes even up to the scapula
. a closer look at this patient 's pain drawing ( fig.1 ) shows that its character is by far exceeding the radicular pattern usually seen in sciatica .
clinically , one needs to discriminate the pain in the anterior part of the leg caused by irritation of a l5-nerve root from the pain caused by an anterior ccs and correspondingly by the other compartments .
recently clinical examination proved more adequate than pressure measurement in deciding how many compartments need fasciotomy in order to achieve permanent pain free legs .
the technique of fasciotomy of all four leg compartments , paralleling the general recommendation in acute cases , was adapted toward modern endoscopic principles in order to evade disturbing scars whilst trying not to damage local nerves ( fig.2 ) . in the same study
, ccs was associated with leg cramps in 86.5% of patients and hormonal disturbances occurred in 30% .
possibly ccs and other peripheral nerve entrapments might be caused by edema from some systemic disease .
the fascias were split by distances of 20 cm in the anterior , lateral and superficial posterior compartments , whereas the fascias of the deep posterior compartments were split by distances of 10 cm . in conclusion , a diagnosis of ccs should be anticipated if ( 1 ) leg pain or cramps are caused both by walking and running , leading to awakening at night , ( 2 ) radiological findings are normal and ( 3 ) neurological changes are limited to numbness or reduced sensitivity in the forefoot areas of the nervus fibularis profundus , the nervus fibularis superficialis , and/or the nervus suralis .
the risks for the fetus from high - dose opioid treatment remains unclear , but negative effects can not be ruled out .
if no treatment is adequate to ensure a bearable pain situation for the patient during the pregnancy , surgery can be considered .
but only after careful consideration of the risks associated and thorough information and consent of the patient .
this patient clearly expressed that she would have preferred the surgical procedure early in the pregnancy rather than post partum .
airway management can be impaired due to upper airway edema and vascular changes caused by the hormonal state .
studies have shown a 3.3% risk for difficult intubation and 0.4% risk for failed intubation during pregnancy .
there is also an increased risk for esophageal regurgitation and aspiration due to decreased esophageal sphincter tonus during pregnancy combined with difficult manageable airways .
in addition , the time to desaturate is decreased in the pregnant patient due to increased oxygen consumption and a decreased functional residual capacity .
van de welde et al . reviewed anesthesia to the pregnant patient and concluded that the drugs used today in general anesthesia are not considered to be teratogenic .
there are , however , several studies that link surgery during pregnancy with increased rate of spontaneous abortions , low - birth - weight and death within 168 h of live born infants .
the risks of hypovolemia and hypoxemia for the fetus are increased , however , due to the systematic hemodynamic effects such as vasodilatation and cardiac depression in the mother .
one study found the risk associated with general anesthesia during pregnancy to be a 17-fold increase in complications when compared to regional anesthesia .
the main concerns when performing surgery in regional anesthesia are hypotension and local anesthetic toxicity or anaphylaxis . the procedure can be handled in the same way as a caesarian section in regional anesthesia .
precautions should be undertaken , and appropriate vasopressors must be ready , to be prepared for hypotension and anaphylaxis as a result of injection of local anesthetics . it is recommended to perform the surgery in the second trimester and elective surgery should be avoided .
the reported patient was given opioids ( morphine ) for pain relief during the pregnancy .
the norwegian drug information catalogue lists long - lasting morphine use during pregnancy as a possible agent for neonatal abstinence syndrome with symptoms as cramps , irritability , vomiting , and increased mortality .
the fda - approved box - labeling according to uptodate lists morphine as a class c drug (  risks can not be ruled out  ) during pregnancy . according to the warning , morphine has not shown teratogenic effects in animal studies , but reduced growth and behavior abnormalities in offspring have been observed .
the frequency of congenital malformations has not been reported to be greater than expected in children from mothers treated with morphine during pregnancy .
the recommendation is to use minimal , if any , opioids during pregnancy in patients with chronic non cancer pain . the risk of analgesics for pain during pregnancy must be weighed against the risks associated with surgery during pregnancy .
she did not receive nonpharmacological treatment as iron replacement , mental training , leg stretching or elastic stockings .
at this young age , the presence of differential diagnoses like arteriosclerosis and venous insufficiency may be excluded by clinical examination only .
unspecific neuritis , polyneuritis , diabetic neuropathy , and spinal lesions must be excluded as well .
it might appear a paradox that normal results from electrophysiological examination are reported while changes of sensitivity are found .
pain as an isolated symptom , will usually only affect small and unmyelinated nerve fibers ( small fibers ) .
when the sense of touch is diminished , as is the case with our patient , you would expect an effect on myelinated fibers ( a - alpha ) .
the challenge is that a wide range of normal values for the standard parameter of nerve conduction exists .
our patient had symptoms from both lower extremities , if not we could have increased the sensitivity by comparing to the healthy side .
pain drawing has proven of value in discriminating a radicular pain caused by the l5-or s1-nerve roots from leg pain caused by ccs and possibly its referred pain to the trochanter and lumbar region , sometimes even up to the scapula
. a closer look at this patient 's pain drawing ( fig.1 ) shows that its character is by far exceeding the radicular pattern usually seen in sciatica .
clinically , one needs to discriminate the pain in the anterior part of the leg caused by irritation of a l5-nerve root from the pain caused by an anterior ccs and correspondingly by the other compartments .
recently clinical examination proved more adequate than pressure measurement in deciding how many compartments need fasciotomy in order to achieve permanent pain free legs .
the technique of fasciotomy of all four leg compartments , paralleling the general recommendation in acute cases , was adapted toward modern endoscopic principles in order to evade disturbing scars whilst trying not to damage local nerves ( fig.2 ) .
in the same study , ccs was associated with leg cramps in 86.5% of patients and hormonal disturbances occurred in 30% .
possibly ccs and other peripheral nerve entrapments might be caused by edema from some systemic disease .
, symmetrical skin incisions were performed in the right and left legs . on the left leg ,
the fascias were split by distances of 20 cm in the anterior , lateral and superficial posterior compartments , whereas the fascias of the deep posterior compartments were split by distances of 10 cm . in conclusion , a diagnosis of ccs should be anticipated if ( 1 ) leg pain or cramps are caused both by walking and running , leading to awakening at night , ( 2 ) radiological findings are normal and ( 3 ) neurological changes are limited to numbness or reduced sensitivity in the forefoot areas of the nervus fibularis profundus , the nervus fibularis superficialis , and/or the nervus suralis .
the risks for the fetus from high - dose opioid treatment remains unclear , but negative effects can not be ruled out .
if no treatment is adequate to ensure a bearable pain situation for the patient during the pregnancy , surgery can be considered .
but only after careful consideration of the risks associated and thorough information and consent of the patient .
this patient clearly expressed that she would have preferred the surgical procedure early in the pregnancy rather than post partum .
the authors report no conflicts of interest . the authors alone are responsible for the content and writing of the paper .
 key clinical messagea case of intolerable leg pain in pregnancy , caused by chronic compartment syndrome ( ccs ) , is presented . 
 increasing amounts of opioids were given throughout the pregnancy . 
 anesthetical dilemmas and surgery are discussed . in conclusion , 
 early surgery rather than opioids is recommended . 
Key Clinical Message
Introduction
Case Report
Discussion
Anesthetical considerations concerning fasciotomy during pregnancy
Diagnostic considerations
Conflict of Interest