M u s c u l o s k e l e t a l I m a g i n g • R ev i ew Proisy et al. Musculoskeletal Disorders in Pregnancy
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Musculoskeletal Imaging Review
Imaging of Musculoskeletal Disorders Related to Pregnancy Maïa Proisy 1 Alban Rouil2 Hélène Raoult 3 Céline Rozel 4 Pascal Guggenbuhl2 Denis Jacob 5 Raphaël Guillin 6 Proisy M, Rouil A, Raoult H, et al.
Keywords: delivery, MRI, musculoskeletal imaging, postpartum, pregnancy DOI:10.2214/AJR.13.10988 Received March 31, 2013; accepted after revision August 22, 2013. 1 Department of Imaging, CHU de Rennes–Hôpital Sud, Rennes, France. 2 Department of Rheumatology, CHU de Rennes–Pontchaillou, Rennes, France. 3 Department of Imaging, Division of Neuroradiology, CHU de Rennes–Pontchaillou, Rennes, France. 4 Department of Imaging, Division of Pediatric, Fetal, and Gynecologic Imaging, CHU de Rennes–Hôpital Sud, Rennes, France. 5
Department of Imaging, CHU de Dijon, Dijon, France.
6 Department of Imaging, Division of Musculoskeletal Imaging, CHU de Rennes–Hôpital Sud, Blvd de Bulgarie, Hôpital Sud, BP 90347, Rennes 35203, Ille et Vilaine, France. Address correspondence to R. Guillin ([email protected]).
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OBJECTIVE. This article provides an overview of the typical appearance of biomechanical and physiologic changes in pregnancy and an update on related pathophysiology. Conditions occurring during the childbearing, delivery and postpartum periods will be reported separately. CONCLUSION. Pregnancy causes biomechanical and physiologic changes that may be responsible for a wide spectrum of musculoskeletal disorders in the mother.
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regnancy is a condition in which a combination of biomechanical, hormonal, and vascular changes may result in a wide variety of musculoskeletal disorders. Stress on the axial skeleton, pelvic brim, and genital tract during childbearing and childbirth may lead to acute disorders, including nonspecific pain, neurologic compression, joint disruption, and hematogenous infections. The effects of pregnancy on certain preexisting conditions, such as rheumatism, desmoid tumors, and vascular malformations also warrant discussion. Likewise, morphologic bone changes are held by some authors to be related to pregnancy. In the postpartum period, baby care may lead to specific disorders of the mother’s upper limbs. Although some clinical articles have attempted to review the main musculoskeletal disorders related to pregnancy [1–4], no work has proposed an overview of the topic on the basis of imaging findings. We propose to review the main musculoskeletal disorders during pregnancy, delivery, and the postpartum period and to discuss the main features and role of imaging. Pregnancy Disorders Arising During Pregnancy Pelvic girdle syndrome and low back pain— Low back and pelvic pain are the most common musculoskeletal symptoms during pregnancy. These symptoms are estimated to occur concurrently during pregnancy (45%) and the postpartum period (25%), and their severity requires medical attention in 25% and 5% of cases, respectively [5]. Depending on the study considered, isolated low back pain occurs in between 24% and 90%
of cases [6]. During pregnancy, low back pain results from multiple factors, including anterior displacement of the body’s center of gravity with loss of tone in the abdominal wall that normally acts as a spinal stabilizer [7]. In the pelvic girdle, pregnancy leads to subsequent overload in joints and surrounding ligaments. Additionally, production of the hormone relaxin during pregnancy contributes to ligamentous hyperlaxity with subsequent stress on the pelvic girdle joints [8]. Pain is typically located in the sacroiliac joint and buttocks area and radiates through the posterior aspect of the thighs without true radiculalgia [7, 9]. Clinical examination is usually sufficient for diagnosis. Imaging is only used in cases in which uncontrolled pain requires a more severe differential diagnosis to be ruled out. Osteoporosis and stress fractures—Because the bone mineral density (BMD) before pregnancy is usually unavailable, it is unclear whether pregnancy reveals preexisting osteoporosis or is an isolated risk factor for osteoporosis and associated fractures [10]. Pelvic and hip stress fractures during pregnancy or immediately postpartum may have different causes depending on the metabolic status of the patient. A “fatigue fracture” occurs in a normal bone exposed to overload, whereas an insufficiency fracture occurs in a weakened bone withstanding a normal biomechanical load. Although Møller et al. [10] have shown that BMD decreases during pregnancy and continues after delivery when breastfeeding, occurrence of true osteoporosis remains unusual. Postpartum vertebral osteoporosis has been reported within 3 months of delivery,
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Musculoskeletal Disorders in Pregnancy usually during lactation. Lumbar BMD decreases, but hip BMD usually does not. Clinical presentation related to vertebral fractures includes intense back pain and height loss. In the case of a new pregnancy, vertebral fractures may occur in one third of cases [11]. On MRI, sacral stress fractures are usually visible as a thin line of low signal intensity lying 1–2 cm parallel to the sacroiliac joint and surrounded by bone edema [12]. Stress fractures of the femoral head are usually located on the anterior and superior aspect of the femoral head, an area of maximum load during gait. MRI is preferred over CT both for imaging pregnant patients and, more generally, for evaluating bone marrow. In stress fractures of the femoral head, subchondral bone fractures may be seen as curvilinear lines or bands of low signal intensity lying parallel to the subchondral bone and surrounded by edema [13]. This appearance is considered highly specific and differs from that of osteonecrosis of the femoral head in which a serpiginous line of demarcation with double signal intensity extends to the subchondral bone on both sides and delineates the zone of infarction [14] (Fig. 1). Hip: subchondral bone disease—Symptomatic hip disease remains rare compared with nonspecific pelvic pain and usually occurs in the third trimester of pregnancy or in the early postpartum period, with an overall estimated incidence of 0.06% [15]. Because of the association of hormonal, metabolic, and mechanical factors, the subchondral bone of the femoral head may be especially affected by transient osteoporosis of the hip, osteonecrosis of the femoral head, or stress fractures of the femoral head. In a consecutive study of 4900 pregnant women, transient osteoporosis of the hip and stress fractures of the femoral head accounted for the vast majority of hip-related diseases, whereas osteonecrosis of the femoral head was far less prevalent, posing the question of its relation to pregnancy [15]. However, the association was suggested in another work in which none of the 13 cases reported any risk factor other than pregnancy [16]. Transient osteoporosis of the hip is typically associated with young or middle-age men [17, 18] and the third trimester of pregnancy in women [15, 19–21]. After early onset, intense hip pain preventing gait usually contrasts with an absence of hip limitation on clinical examination [17, 19]. Involvement is bilateral in one third of cases [20]. Because radiographs may show lucency of the femoral head [17], MRI should be pre-
ferred as a first-line modality during pregnancy because it can depict subchondral bone edema of the femoral head with occasional joint effusion from the early stages of the disease [22, 23] (Fig. 2). The presence of associated subchondral bone fractures, seen as a thin line of low signal intensity parallel to the subchondral bone [23, 24], is not rare and may lead to confusion with primitive stress fractures of the femoral head. Differentiating the two conditions is nevertheless of limited importance because both conditions are reversible and have a self-limiting course compared with osteonecrosis of the femoral head. Disk herniation and sciatica—True sciatica remains rare and is estimated to occur in 1% of pregnancies [25]. The relationship between pregnancy and disk herniation remains controversial. Some studies report a higher risk during pregnancy and parity [26], whereas others consider a young to middle age in childbearing women to be a sufficient risk factor for the condition [27]. As it does in the general population, MRI has to be correlated with symptoms, and imaging is only required in cases of uncontrolled pain, motor deficiency, or the presence of other spinal canal stenosis symptoms. MRI without injection of contrast medium is the modality of choice owing to the lack of ionizing radiation [28]. In addition to disk herniation, enlarged epidural veins, or varices, resulting from mass effect on the inferior vena cava have, in rare instances, been reported to cause radiculopathies in the general [29, 30] and pregnant population [31, 32]. The signal intensity of enlarged veins depends on blood velocity and the presence or absence of areas of thrombus [29]. Complete resolution usually occurs after delivery. Carpal tunnel syndrome—Carpal tunnel syndrome occurs in 7–43% of cases during pregnancy and is especially prevalent during the second and third trimesters [33]. It is bilateral in 70–80% of cases and results from hormonal changes with associated fluid retention in the tendon sheaths located within the carpal tunnel [34]. Imaging is usually not required. Ultrasound may nevertheless guide steroid injections in severe cases. Symptoms usually gradually subside after delivery but may persist mildly in 50% of patients for 1 year and in 30% of patients for 3 years after delivery [33]. Meralgia paresthetica and neuralgia of the abdominal wall—The mass effect of the pregnant womb and changes in thoracolumbar posture may result in stretching or compression of the superficial nerves running through
the abdominal wall. The lateral cutaneous nerve of the thigh [1], lower intercostal nerves [35], and iliohypogastric nerve may be involved [36]. Only the lateral cutaneous nerve of the thigh is visible on ultrasound (Fig. 3), which can be used to guide steroid injection [37]. Injection of other nerves can be guided by CT and neurostimulation (Kastler B, et al., presented at the 2002 annual meeting of the Radiological Society of North America). Development of Preexisting Disorders Although not caused by pregnancy, physiologic changes related to the condition may, in a given patient, accelerate the course of a known or unknown preexisting musculoskeletal condition, notably arteriovenous malformations (AVM), desmoid tumors, and rheumatoid arthritis and related disorders. Vascular malformations— Soft-tissue AVMs are predominantly located in cervicofacial areas [38]. They are known to be sensitive to hormonal changes and become particularly symptomatic during the third trimester of pregnancy, which can reveal previously unrecognized AVMs or cause expansion of preexisting lesions [39]. These symptoms may be due to the progressive increase in both maternal blood volume and associated venous pressure, whereas an increase in progesterone and estrogen rates leads to venous dilation and vascular proliferation, respectively [39]. Although the risk of bleeding in CNS AVMs is known to be 10 times higher in pregnant women than in the general population [40], no data relative to soft-tissue AVMs is available in the literature. Imaging with Doppler ultrasound shows a poorly defined lesion comprising a network of enlarged vessels, associating feeding arteries with high diastolic flow, and draining veins with systolic-diastolic flow [41]. MRI is useful in assessing deep extension of lesions into soft tissues and underlying bones [38]. High-flow serpentine feeding arteries and draining veins appear as signal voids on both T1-weighted and T2-weighted spin-echo sequences and as high-signalintensity structures on gradient-echo and angiographic sequences (Fig. 4). Gadolinium-enhanced MR angiography can detect arteries and veins and differentiate between hemorrhage, intravascular thrombosis, and intravascular flow [42]. Soft-tissue AVM management is usually aimed at lesion control rather than cure, with a high risk of flare-up when surgical or endovascular removal is attempted. Low-flow vascular lesions, such as venous malforma-
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Proisy et al. tions, have a lower potential for progression. In AVMs, repeated thrombosis of the lesion may lead to coagulopathy that should be detected before delivery to prevent uncontrolled bleeding [43, 44]. Concurrently, some locations of the lesion in the lumbar or pelvic areas may prevent procedures such as lumbar puncture or vaginal delivery when lesions are located around the vaginal tract, lumbar soft tissues, or epidural space. MRI is the best modality for assessing these lesion extensions (Fig. 5). Progression of vertebral hemangioma has also been reported in the course of pregnancy, sometimes requiring surgical decompression [45, 46]. MRI is also the preferred modality in pregnancy, confirming the usual pattern of aggressive vertebral angioma [47]. Deep musculoskeletal fibromatosis—Deep musculoskeletal fibromatosis, also known as desmoid tumor, results from focal proliferation of benign fibrous tissue within muscles. Trauma and pregnancy are the main risk factors for the disease. Abdominal wall lesions are especially prevalent in women of childbearing age [48]. The role of estrogen as a growth factor for the lesion is suggested because of the increase in size of these tumors during the third trimester of pregnancy, their high prevalence in women taking birth control pills, and their tendency to regress after menopause [49]. Ultrasound is the first-line modality and shows a heterogeneous hypoechoic lesion with the muscle that has blurry margins and a possible hypervascular pattern on color Doppler imaging [50]. MRI is well suited to assessing deep extension of these lesions (Fig. 6). Lesions are usually centered in the intermuscular fascia and have the ability to invade neighboring structures, such as muscles or, more rarely, neurovascular elements, with a subsequent functional risk for the limb involved. Lesions are usually heterogeneous, including areas of collagen with typical low signal intensity and areas with more cellular content. The former areas may have a linear organization considered to be almost pathognomonic, whereas the latter areas may show various enhancements depending on the amount of vascular content [51]. Although imaging is highly suggestive of the diagnosis, biopsy is usually required for histopathologic confirmation. Rheumatoid arthritis and related diseases— The outcome of rheumatoid arthritis is typically good; symptoms improve in 75% of patients in the early stage of pregnancy despite relapse occurring in 90% of cases after delivery [52]. Complete remission is sponta-
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neously observed in between 16% and 65% of patients depending on the studies and remission definitions [53, 54], and treatment remains necessary in other cases. The evolution of spondyloarthropathies is less stereotypical. Despite controversy among existing studies, it is acknowledged that during pregnancy ankylosing spondylitis remains stable in 40% of cases, improves in 30%, and worsens in the remaining 30%. Worsening is particularly significant in patients with preexisting spinal involvement, probably due to the combined effect of mechanical and inflammatory factors [55]. Despite the lack of guidelines for imaging follow-up in pregnant women, ultrasound and MRI may be useful for monitoring rheumatoid arthritis and ankylosing spondylitis, respectively. In severe cases, imaging-guided steroid injections may be attempted. Childbirth Cephalopelvic disproportion may lead to dystocia and perinatal asphyxia. When suspected, this condition should be confirmed to plan a cesarean delivery. In this case, measurement of the pelvic brim in different planes is routinely offered to patients with risk factors. CT is currently the modality of choice compared with radiography because of the lower radiation dose and more accurate imaging [56]. MRI has also been evaluated in the past few years [57] but requires a longer examination time and involves higher cost. Apart from the risk to the fetus, vaginal delivery also exerts a high degree of stress on the mother’s pelvic brim and neighboring structures, with a subsequent risk of nerve compression and joint distention. Lumbosacral Plexopathy Lumbosacral plexopathy, also referred to as “intrapartum maternal lumbosacral plexopathy,” is a well-known delivery complication that results from compression of the lumbosacral trunk by the descending fetal head against the sacral wing [58, 59]. Patients typically report acute radiculopathy during delivery, with subsequent foot drop during the postpartum period. In a study by Katirji et al. [58], the right side was involved in six of seven cases, probably due to the higher prevalence of left occiput anterior orientation of the fetal head. Neural lesions usually recover within a few months. MRI is known to provide gross analysis of the lumbosacral plexus branches [60]. In the case of intrapartum maternal lumbosacral plexopathy, MRI can
show hypertrophy of the involved nerve roots with associated high signal intensity on T2weighted sequences, thus confirming the injury mechanism (Fig. 7). Recent advances with the use of 3D anatomic nerve-selective MR neurography based on diffusion-weighted sequences with directional encoding may help to emphasize focal impairment of the lumbosacral plexus in cases of intrapartum maternal lumbosacral plexopathy [61, 62]. The differential diagnosis of postpartum radicular or truncular deficiency includes pyomyositis or hematoma of the piriformis muscle due to prolonged labor [63, 64]. Disorders of the Symphysis Pubis Stress on the pelvic girdle that occurs during pregnancy and increases during delivery may be responsible for acute changes to the symphysis pubis. For example, widening and the presence of gas on CT may be seen frequently in the pubic symphysis in nonsymptomatic patients who have undergone an uncomplicated delivery [65]. Similarly, MRI of nonsymptomatic pelvic ring joints performed in the immediate postpartum period may reveal higher water content of the pubic cartilage and focal edematous changes to the parasymphyseal pubis bones [66]. In rare instances, load applied to the pelvic brim may exceed joint capabilities and lead to disruption and pain of the pubic symphysis. Prevalence of this complication is estimated to range between 1 in 521 and 1 in 20,000 childbirths [67]. Diastasis of the pubic bone up to 47 mm may be observed on radiographs [67] and is usually associated with various degrees of widening of the sacroiliac joints. On ultrasound, Scriven et al. [68] showed a gap larger than 10 mm as confirming the diagnosis of disruption, whereas absence of reduction was associated with persistence of symptoms over time for one patient. MRI may show fluid within the symphysis pubis [69]. Treatment is usually conservative [67, 70]. Sacrococcygeal Dislocation and Coccygodynia Coccygodynia is defined as pain in the coccyx area occurring in the sitting position [71]. Childbirth is a common cause, estimated to explain 7.3% of chronic coccygodynia in women [71]. Difficult deliveries and a short perineum are the two main risk factors for this condition [71]. Symptoms usually arise the day after delivery as soon as the patient adopts a sitting position [71]. Abnormalities in the area of the sacrococcygeal joint
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Musculoskeletal Disorders in Pregnancy may be evaluated with static and dynamic lateral radiography in the standing and sitting positions [72] (Fig. 8). The coccyx may be considered rigid when fused with the sacrum, normal when flexion or extension on dynamic radiography remains between 5° and 25°, hypermobile when it is above 25° flexion, or dislocated when translated backward [73]. Dislocation and severe hypermobility (above 35°) are typically associated with symptoms [74]. Although normal mobility and hypermobility are often encountered, posterior dislocation of the coccyx appeared to be specifically related to childbirth compared with an age-matched control group [71]. In far more rare instances, a true fracture of the coccyx or fifth sacral vertebra may occur and lead to pseudarthrosis [71]. In a recent study, MRI was recommended as a second-line modality when radiography fails to provide an adequate explanation for symptoms. Despite the lack of a control group, the authors suggested that intraosseous edema or changes to the soft tissue surrounding the sacrococcygeal joint may reflect a source of pain [75]. Postpartum Early Postpartum Apart from pain resulting from the previously mentioned articular or neural trauma, the early postpartum period may see the occurrence of additional disorders related to childbirth, such as maternal infection and, later on, specific abnormality of the mother’s wrist due to baby care. Septic arthritis—Despite being a rare condition, infectious sacroiliitis may be related to delivery and occur in the early postpartum period [76–78]. Hematogenous contamination of the joint results from a simple injury to the genital tract and may coexist with urinary tract infection or endometritis; Staphylococcus aureus is the most prevalent organism encountered [76]. Because of the high prevalence of nonspecific lumbar pain and inconsistent presence of clinical and biologic signs of inflammation in the postpartum period, MRI should be performed as soon as the diagnosis is suspected. Involvement is typically unilateral, with inflammatory signs in both subchondral bone and neighboring soft tissues [79] (Fig. 9). Other reported pelvic infections in the postpartum period include piriformis muscle abscess resulting from a direct forceps injury [64] and osteomyelitis of the pubic symphysis [80].
Baby wrist—Wrist overuse associated with baby care in the postpartum period is known to cause de Quervain tenosynovitis [1, 3]. In a study by Anderson et al. [81], de Quervain tenosynovitis occurred an average of 8 months after childbirth and was associated with the height and weight of babies above the 95th percentile, emphasizing the role of mechanical stress. However, in some instances, association with carpal tunnel syndrome during pregnancy suggests the contribution of hormonal changes to the disease [82]. MRI can confirm thickening of the first compartment tendons and surrounding tissues with hyperintensity on T2weighted sequences. Ultrasound can confirm the diagnosis, is more readily available and affordable, and has a similar accuracy to MRI [83]. Symptoms usually resolve with rest and conservative treatment; however, local steroid injections are known to offer better results in pregnant women than in the general population [84, 85]. Late Postpartum Paraglenoid sulcus—Paraglenoid sulcus is a groove in the iliac bone adjacent and lying parallel to the inferior sacroiliac joint. This finding is routinely used for sex determination in forensic and anthropologic practice [86]. In a study by Dee [87], a typical paraglenoid sulcus was found in 25% of women. In men, sulci are considered to be less prevalent (6% of patients in the study by Dee), more shallow [88, 89], and associated with a triangular-shaped pelvic brim [87]. From a pathophysiologic viewpoint, paraglenoid sulcus is understood to result from traction of the inferior part of the ventral sacroiliac ligament at its site of attachment to the iliac bone (Fig. 10). Anatomic works have shown this ligament to insert on the iliac wing a few millimeters lateral to the sacroiliac joint, a site that precisely hosts the paraglenoid sulcus [90]. Despite controversy [91], this finding is considered by some authors to represent a marker of pregnancy and parturition [89, 92], particularly when the groove is deep [93]. This finding is easily recognized on anterior radiographs of the pelvis (Fig. 11). Analysis with CT excluded the theory that paraglenoid sulcus represents a vascular channel for hypogastric vessels [93], which was advanced in a former study [94]. Osteitis condensans ilii—Osteitis condensans ilii is an area of bone sclerosis arising on the inferior aspect of the iliac bone adjacent to
the sacroiliac joint and occurring bilaterally in 76–87% of cases [95, 96]. A more recent study using CT has shown the sacral bone to be involved by sclerosis in some cases [97]. This condition has been associated with low back pain, tenderness of the sacroiliac joint [96], paraglenoid sulcus, and increased lumbar lordosis [93]. Its prevalence remains low, estimated at between 0.9% and 2.5% of the general population [98]. Numerous studies have shown high prevalence of osteitis condensans ilii in women with previous pregnancies [95, 99, 100]. Nevertheless, other works have suggested that pregnancy is not an exclusive risk factor for osteitis condensans ilii because this finding is sometimes reported in men with high physical activity [101] and nulliparous women [100]. When followed, osteitis condensans ilii has been shown to be reversible over time in up to 76% of cases [95]. Residual joint pain and associated remodeling—As mentioned previously, lumbar spine, sacroiliac, pubic symphysis, and sacrococcygeal joints may, in rare instances, remain symptomatic [67, 71]. In the pubic symphysis, degenerative articular cysts have rarely been considered to result from childbearing [102–104]. When the lesion develops posteriorly, it may impinge on the urinary tract and cause dysuria [103]. MRI can confirm the diagnosis and depict deep extension of the lesion [102]. Assessment with ultrasound and CT has also been reported [105]. Conclusion Musculoskeletal disorders related to pregnancy mainly result from overload and occur during the childbearing period and delivery. Nevertheless, this transient period of life may lead to ongoing disorders or morphologic changes on imaging that require detailed understanding and accurate diagnosis by radiologists. References 1. Ritchie JR. Orthopedic considerations during pregnancy. Clin Obstet Gynecol 2003; 46:456–466 2. Sax TW, Rosenbaum RB. Neuromuscular disorders in pregnancy. Muscle Nerve 2006; 34:559–571 3. Heckman JD, Sassard R. Musculoskeletal considerations in pregnancy. J Bone Joint Surg Am 1994; 76:1720–1730 4. Musielak-Zanetti C, Flipo RM, Cotten A. Quelle imagerie au cours de la grossesse? Rev Rhum Ed Fr 2005; 72:750–754 5. Wu WH, Meijer OG, Uegaki K, et al. Pregnancyrelated pelvic girdle pain (PPP). I. Terminology,
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on 14 women. AJR 1989; 153:1239–1241 66. Wurdinger S, Humbsch K, Reichenbach JR, Peiker G, Seewald HJ, Kaiser WA. MRI of the pelvic ring joints postpartum: normal and pathological findings. J Magn Reson Imaging 2002; 15:324–329 67. Kowalk DL, Perdue PS, Bourgeois FJ, Whitehill R. Disruption of the symphysis pubis during vaginal delivery: a case report. J Bone Joint Surg Am 1996; 78:1746–1748 68. Scriven MW, Jones DA, McKnight L. The importance of pubic pain following childbirth: a clinical and ultrasonographic study of diastasis of the pubic symphysis. J R Soc Med 1995; 88:28–30 69. Kurzel RB, Au AH, Rooholamini SA, Smith W. Magnetic resonance imaging of peripartum rupture of the symphysis pubis. Obstet Gynecol 1996; 87:826–829 70. Nitsche JF, Howell T. Peripartum pubic symphysis separation: a case report and review of the literature. Obstet Gynecol Surv 2011; 66:153–158 71. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med 2012; 48:387–392 72. Maigne JY, Guedj S, Straus C. Idiopathic coccygodynia: lateral roentgenograms in the sitting position and coccygeal discography. Spine 1994; 19:930–934 73. Maigne JY, Tamalet B. Standardized radiologic protocol for the study of common coccygodynia and characteristics of the lesions observed in the sitting position: clinical elements differentiating luxation, hypermobility, and normal mobility. Spine 1996; 21:2588–2593 74. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine 2000; 25:3072–3079 75. Maigne JY, Pigeau I, Roger B. Magnetic resonance imaging findings in the painful adult coccyx. Eur Spine J 2012; 21:2097–2104 76. Almoujahed MO, Khatib R, Baran J. Pregnancyassociated pyogenic sacroiliitis: case report and review. Infect Dis Obstet Gynecol 2003; 11:53–57 77. Ducrotoy V, Fournet P, Vittecoq O, Daragon A. Postpartum septic arthritis: two case reports [in French]. J Gynecol Obstet Biol Reprod (Paris) 1998; 27:449–454 78. Haq I, Morris V. Post-partum septic sacroiliitis. Rheumatology (Oxford) 2001; 40:1191–1192 79. Stürzenbecher A, Braun J, Paris S, Biedermann T, Hamm B, Bollow M. MR imaging of septic sacroiliitis. Skeletal Radiol 2000; 29:439–446 80. Dunk RA, Langhoff-Roos J. Osteomyelitis of the pubic symphysis after spontaneous vaginal delivery. BMJ Case Rep 2010; 2010:ii 81. Anderson SE, Steinbach LS, De Monaco D, Bo-
nel HM, Hurtienne Y, Voegelin E. “Baby wrist”: MRI of an overuse syndrome in mothers. AJR 2004; 182:719–724 82. Schumacher HR Jr, Dorwart BB, Korzeniowski OM. Occurrence of De Quervain’s tendinitis during pregnancy. Arch Intern Med 1985; 145:2083–2084 83. Giovagnorio F, Andreoli C, De Cicco ML. Ultrasonographic evaluation of de Quervain disease. J Ultrasound Med 1997; 16:685–689 84. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg Am 2002; 27:322–324 85. Capasso G, Testa V, Maffulli N, Turco G, Piluso G. Surgical release of de Quervain’s stenosing tenosynovitis postpartum: can it wait? Int Orthop 2002; 26:23–25 86. Novak L, Schultz JJ, McIntyre M. Determining sex of the posterior ilium from the Robert J. Terry and William M. Bass collections. J Forensic Sci 2012; 57:1155–1160 87. Dee PM. The preauricular sulcus. Radiology 1981; 140:354 88. Davivongs V. The pelvic girdle of the Australian aborigine; sex differences and sex determination. Am J Phys Anthropol 1963; 21:443–455 89. Houghton P. The relationship of the pre-auricular groove of the ilium to pregnancy. Am J Phys Anthropol 1974; 41:381–389 90. Jaovisidha S, Ryu KN, De Maeseneer M, et al. Ventral sacroiliac ligament: anatomic and pathologic considerations. Invest Radiol 1996; 31:532–541 91. Spring DB, Lovejoy CO, Bender GN, Duerr M. The radiographic preauricular groove: its nonrelationship to past parity. Am J Phys Anthropol 1989; 79:247–252 92. Kelley MA. Parturition and pelvic changes. Am J Phys Anthropol 1979; 51:541–546 93. Schemmer D, White PG, Friedman L. Radiology of the paraglenoid sulcus. Skeletal Radiol 1995; 24:205–209 94. Ferguson AB. A groove for the hypogastric vessels. J Bone Joint Surg Am 1931; 13:568–569 95. Numaguchi Y. Osteitis condensans ilii, including its resolution. Radiology 1971; 98:1–8 96. Jenks K, Meikle G, Gray A, Stebbings S. Osteitis condensans ilii: a significant association with sacroiliac joint tenderness in women. Int J Rheum Dis 2009; 12:39–43 97. Olivieri I, Ferri S, Barozzi L. Osteitis condensans ilii. Br J Rheumatol 1996; 35:295–297 98. Mitra R. Osteitis condensans ilii. Rheumatol Int 2010; 30:293–296 99. Hare HF, Haggart E. Osteitis condensans ilii. JAMA 1945; 128:723–727 100. Shipp FL, Haggart GE. Further experience in the management of osteitis condensans ilii. J Bone
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CA. Subpubic cartilaginous cyst presenting as acute urinary retention: a report and review of the literature. Female Pelvic Med Reconstr Surg 2013; 19:58–60 104. Sava MR, Rubin B, Sundaram M. Subpubic cyst: subpubic degenerative cyst arising from the fi-
brocartilage of the pubic symphysis. Skeletal Radiol 2012; 41:851–852, 867–868 105. Ergun T, Lakadamyali H, Aydin O. Subpubic cartilaginous cyst: incidental finding detected by abdominopelvic computed tomography. Radiat Med 2008; 26:46–49
Fig. 1—32-year-old woman with stress fracture of right femoral head. Patient reported rapidly progressing right hip pain occurring at 8 months of pregnancy. A, Coronal fat-saturated T2weighted MR image obtained during early postpartum period shows joint effusion (arrowhead) and subtle low-signal-intensity linear image parallel to subchondral bone of right femoral head, corresponding to fracture line (arrow). Enlarged uterus is also visible (asterisk). B, Sagittal fat-saturated T2weighted MR image of right hip also shows fracture line (arrow).
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Fig. 2—36-year-old woman with bilateral transient osteoporosis of femoral heads. Pain initially occurred on left hip after seventh month of pregnancy, followed by contralateral side 3 weeks later. A, Coronal fat-saturated T2-weighted MR image obtained during early postpartum period shows enlarged uterus (asterisk), bilateral bone marrow edema of femoral heads (arrowheads), and joint effusion (arrows). B, Bone marrow edema is also seen on coronal T1-weighted MR image as slight low signal intensity of femoral heads with no fracture or osteonecrosis line.
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Musculoskeletal Disorders in Pregnancy
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Fig. 3—29-year-old woman who presented with meralgia paresthetica of right thigh during ninth month of pregnancy. A, Short-axis ultrasound images over anterior superior iliac spine (ASIS) show ilioinguinal ligament (arrowheads) and swelling and hypoechogenicity of right lateral femoral cutaneous nerve (arrows) when compared with contralateral side. B, Long-axis ultrasound image over right lateral femoral cutaneous nerve at level of anterior superior iliac spine shows pathologic features in longitudinal plane on right side (arrows). Proximal portion of nerve (arrowheads) is normal and tiny.
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Fig. 4—30-year-old woman with frontal soft-tissue arteriovenous malformation. A, Photograph shows slight swelling of right forehead since childhood that rapidly enlarged during first pregnancy. B, Sagittal 3D angio-MR image of head and neck shows abnormal frontal number of vessels (arrow) with arterial afferences.
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Fig. 5—30-year-old woman with previously known giant venous malformation of right lower limb and pelvis. A, Axial fat-saturated T2-weighted MR image shows fetal head (arrowhead) and venous malformation (arrows). B, Axial fat-saturated T2-weighted MR image shows venous malformation located on right genital tract (arrow), contraindicating vaginal delivery. (Fig. 5 continues on next page)
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Fig. 5 (continued)—30-year-old woman with previously known giant venous malformation of right lower limb and pelvis. C, Sagittal fat-saturated T2-weighted MR image emphasizes lumbar venous malformation (arrow) that contraindicates epidural anesthesia under L3 vertebra level.
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Fig. 6—30-year-old woman with pathologically proven desmoid tumor of right thigh, with history of rapidly progressing lump during ninth month of pregnancy. A, Coronal STIR MR image shows heterogeneous tumor of right thigh (arrows) including peripheral content with low signal intensity (arrowhead). B, Axial T1-weighted MR image confirms lesion centered underneath (arrows) and within vastus lateralis muscle (asterisk). Low-signal-intensity content is also depicted (arrowhead). C, T1-weighted fat-saturated gadolinium-enhanced MR image in axial plane shows brisk enhancement of central portion of lesion, confirming its cellular and vascular content.
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Musculoskeletal Disorders in Pregnancy Fig. 7—33-year-old woman with acute L5 radiculopathy during delivery and subsequent foot drop and sensory loss. Electrodiagnosis confirmed L5 root impairment. Symptoms progressively resolved within 6 months. A, Axial T1-weighted MR image shows hypertrophy of right L5 root compared with contralateral side (circles). B, Coronal STIR MR image shows spontaneous hyperintensity of right L5 root compared with contralateral side (arrows).
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Fig. 8—38-year-old woman with persistent coccygodynia 18 months after vaginal delivery. A, Lateral radiograph obtained in standing position shows posterior subluxation of sacrococcygeal joint. B, Lateral radiograph obtained in sitting position shows dislocation of coccyx.
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Proisy et al. Fig. 9—31-year-old woman with right postpartum sacroiliitis. Right gluteal pain started few days after normal delivery. CT-guided biopsy confirmed presence of gram-positive cocci. A, Oblique axial STIR MR image shows enlarged postpartum uterus (asterisk) and increased subchondral signal intensity on both aspects of right sacroiliac joint (arrow). B, Oblique coronal STIR MR image also shows subchondral osteitis of joint (arrow).
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Fig. 10—Asymptomatic 56-year-old woman. Axial T2-weighted MR image shows anatomy of normal ventral sacroiliac ligament (arrows) as thin linear structure traversing sacroiliac joint anteriorly. Insertion of ligament on iliac bone lateral to joint is visible.
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Fig. 11—47-year-old multiparous woman with lumbar pain. Anteroposterior radiograph of pelvis incidentally shows bilateral deep grooves on outer edges of sacroiliac joints (arrows), corresponding to typical paraglenoid sulci.
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Musculoskeletal Imaging Review
Imaging of Musculoskeletal Disorders Related to Pregnancy Maïa Proisy 1 Alban Rouil2 Hélène Raoult 3 Céline Rozel 4 Pascal Guggenbuhl2 Denis Jacob 5 Raphaël Guillin 6 Proisy M, Rouil A, Raoult H, et al.
Keywords: delivery, MRI, musculoskeletal imaging, postpartum, pregnancy DOI:10.2214/AJR.13.10988 Received March 31, 2013; accepted after revision August 22, 2013. 1 Department of Imaging, CHU de Rennes–Hôpital Sud, Rennes, France. 2 Department of Rheumatology, CHU de Rennes–Pontchaillou, Rennes, France. 3 Department of Imaging, Division of Neuroradiology, CHU de Rennes–Pontchaillou, Rennes, France. 4 Department of Imaging, Division of Pediatric, Fetal, and Gynecologic Imaging, CHU de Rennes–Hôpital Sud, Rennes, France. 5
Department of Imaging, CHU de Dijon, Dijon, France.
6 Department of Imaging, Division of Musculoskeletal Imaging, CHU de Rennes–Hôpital Sud, Blvd de Bulgarie, Hôpital Sud, BP 90347, Rennes 35203, Ille et Vilaine, France. Address correspondence to R. Guillin ([email protected]).
AJR 2014; 202:828–838 0361–803X/14/2024–828 © American Roentgen Ray Society
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OBJECTIVE. This article provides an overview of the typical appearance of biomechanical and physiologic changes in pregnancy and an update on related pathophysiology. Conditions occurring during the childbearing, delivery and postpartum periods will be reported separately. CONCLUSION. Pregnancy causes biomechanical and physiologic changes that may be responsible for a wide spectrum of musculoskeletal disorders in the mother.
P
regnancy is a condition in which a combination of biomechanical, hormonal, and vascular changes may result in a wide variety of musculoskeletal disorders. Stress on the axial skeleton, pelvic brim, and genital tract during childbearing and childbirth may lead to acute disorders, including nonspecific pain, neurologic compression, joint disruption, and hematogenous infections. The effects of pregnancy on certain preexisting conditions, such as rheumatism, desmoid tumors, and vascular malformations also warrant discussion. Likewise, morphologic bone changes are held by some authors to be related to pregnancy. In the postpartum period, baby care may lead to specific disorders of the mother’s upper limbs. Although some clinical articles have attempted to review the main musculoskeletal disorders related to pregnancy [1–4], no work has proposed an overview of the topic on the basis of imaging findings. We propose to review the main musculoskeletal disorders during pregnancy, delivery, and the postpartum period and to discuss the main features and role of imaging. Pregnancy Disorders Arising During Pregnancy Pelvic girdle syndrome and low back pain— Low back and pelvic pain are the most common musculoskeletal symptoms during pregnancy. These symptoms are estimated to occur concurrently during pregnancy (45%) and the postpartum period (25%), and their severity requires medical attention in 25% and 5% of cases, respectively [5]. Depending on the study considered, isolated low back pain occurs in between 24% and 90%
of cases [6]. During pregnancy, low back pain results from multiple factors, including anterior displacement of the body’s center of gravity with loss of tone in the abdominal wall that normally acts as a spinal stabilizer [7]. In the pelvic girdle, pregnancy leads to subsequent overload in joints and surrounding ligaments. Additionally, production of the hormone relaxin during pregnancy contributes to ligamentous hyperlaxity with subsequent stress on the pelvic girdle joints [8]. Pain is typically located in the sacroiliac joint and buttocks area and radiates through the posterior aspect of the thighs without true radiculalgia [7, 9]. Clinical examination is usually sufficient for diagnosis. Imaging is only used in cases in which uncontrolled pain requires a more severe differential diagnosis to be ruled out. Osteoporosis and stress fractures—Because the bone mineral density (BMD) before pregnancy is usually unavailable, it is unclear whether pregnancy reveals preexisting osteoporosis or is an isolated risk factor for osteoporosis and associated fractures [10]. Pelvic and hip stress fractures during pregnancy or immediately postpartum may have different causes depending on the metabolic status of the patient. A “fatigue fracture” occurs in a normal bone exposed to overload, whereas an insufficiency fracture occurs in a weakened bone withstanding a normal biomechanical load. Although Møller et al. [10] have shown that BMD decreases during pregnancy and continues after delivery when breastfeeding, occurrence of true osteoporosis remains unusual. Postpartum vertebral osteoporosis has been reported within 3 months of delivery,
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Musculoskeletal Disorders in Pregnancy usually during lactation. Lumbar BMD decreases, but hip BMD usually does not. Clinical presentation related to vertebral fractures includes intense back pain and height loss. In the case of a new pregnancy, vertebral fractures may occur in one third of cases [11]. On MRI, sacral stress fractures are usually visible as a thin line of low signal intensity lying 1–2 cm parallel to the sacroiliac joint and surrounded by bone edema [12]. Stress fractures of the femoral head are usually located on the anterior and superior aspect of the femoral head, an area of maximum load during gait. MRI is preferred over CT both for imaging pregnant patients and, more generally, for evaluating bone marrow. In stress fractures of the femoral head, subchondral bone fractures may be seen as curvilinear lines or bands of low signal intensity lying parallel to the subchondral bone and surrounded by edema [13]. This appearance is considered highly specific and differs from that of osteonecrosis of the femoral head in which a serpiginous line of demarcation with double signal intensity extends to the subchondral bone on both sides and delineates the zone of infarction [14] (Fig. 1). Hip: subchondral bone disease—Symptomatic hip disease remains rare compared with nonspecific pelvic pain and usually occurs in the third trimester of pregnancy or in the early postpartum period, with an overall estimated incidence of 0.06% [15]. Because of the association of hormonal, metabolic, and mechanical factors, the subchondral bone of the femoral head may be especially affected by transient osteoporosis of the hip, osteonecrosis of the femoral head, or stress fractures of the femoral head. In a consecutive study of 4900 pregnant women, transient osteoporosis of the hip and stress fractures of the femoral head accounted for the vast majority of hip-related diseases, whereas osteonecrosis of the femoral head was far less prevalent, posing the question of its relation to pregnancy [15]. However, the association was suggested in another work in which none of the 13 cases reported any risk factor other than pregnancy [16]. Transient osteoporosis of the hip is typically associated with young or middle-age men [17, 18] and the third trimester of pregnancy in women [15, 19–21]. After early onset, intense hip pain preventing gait usually contrasts with an absence of hip limitation on clinical examination [17, 19]. Involvement is bilateral in one third of cases [20]. Because radiographs may show lucency of the femoral head [17], MRI should be pre-
ferred as a first-line modality during pregnancy because it can depict subchondral bone edema of the femoral head with occasional joint effusion from the early stages of the disease [22, 23] (Fig. 2). The presence of associated subchondral bone fractures, seen as a thin line of low signal intensity parallel to the subchondral bone [23, 24], is not rare and may lead to confusion with primitive stress fractures of the femoral head. Differentiating the two conditions is nevertheless of limited importance because both conditions are reversible and have a self-limiting course compared with osteonecrosis of the femoral head. Disk herniation and sciatica—True sciatica remains rare and is estimated to occur in 1% of pregnancies [25]. The relationship between pregnancy and disk herniation remains controversial. Some studies report a higher risk during pregnancy and parity [26], whereas others consider a young to middle age in childbearing women to be a sufficient risk factor for the condition [27]. As it does in the general population, MRI has to be correlated with symptoms, and imaging is only required in cases of uncontrolled pain, motor deficiency, or the presence of other spinal canal stenosis symptoms. MRI without injection of contrast medium is the modality of choice owing to the lack of ionizing radiation [28]. In addition to disk herniation, enlarged epidural veins, or varices, resulting from mass effect on the inferior vena cava have, in rare instances, been reported to cause radiculopathies in the general [29, 30] and pregnant population [31, 32]. The signal intensity of enlarged veins depends on blood velocity and the presence or absence of areas of thrombus [29]. Complete resolution usually occurs after delivery. Carpal tunnel syndrome—Carpal tunnel syndrome occurs in 7–43% of cases during pregnancy and is especially prevalent during the second and third trimesters [33]. It is bilateral in 70–80% of cases and results from hormonal changes with associated fluid retention in the tendon sheaths located within the carpal tunnel [34]. Imaging is usually not required. Ultrasound may nevertheless guide steroid injections in severe cases. Symptoms usually gradually subside after delivery but may persist mildly in 50% of patients for 1 year and in 30% of patients for 3 years after delivery [33]. Meralgia paresthetica and neuralgia of the abdominal wall—The mass effect of the pregnant womb and changes in thoracolumbar posture may result in stretching or compression of the superficial nerves running through
the abdominal wall. The lateral cutaneous nerve of the thigh [1], lower intercostal nerves [35], and iliohypogastric nerve may be involved [36]. Only the lateral cutaneous nerve of the thigh is visible on ultrasound (Fig. 3), which can be used to guide steroid injection [37]. Injection of other nerves can be guided by CT and neurostimulation (Kastler B, et al., presented at the 2002 annual meeting of the Radiological Society of North America). Development of Preexisting Disorders Although not caused by pregnancy, physiologic changes related to the condition may, in a given patient, accelerate the course of a known or unknown preexisting musculoskeletal condition, notably arteriovenous malformations (AVM), desmoid tumors, and rheumatoid arthritis and related disorders. Vascular malformations— Soft-tissue AVMs are predominantly located in cervicofacial areas [38]. They are known to be sensitive to hormonal changes and become particularly symptomatic during the third trimester of pregnancy, which can reveal previously unrecognized AVMs or cause expansion of preexisting lesions [39]. These symptoms may be due to the progressive increase in both maternal blood volume and associated venous pressure, whereas an increase in progesterone and estrogen rates leads to venous dilation and vascular proliferation, respectively [39]. Although the risk of bleeding in CNS AVMs is known to be 10 times higher in pregnant women than in the general population [40], no data relative to soft-tissue AVMs is available in the literature. Imaging with Doppler ultrasound shows a poorly defined lesion comprising a network of enlarged vessels, associating feeding arteries with high diastolic flow, and draining veins with systolic-diastolic flow [41]. MRI is useful in assessing deep extension of lesions into soft tissues and underlying bones [38]. High-flow serpentine feeding arteries and draining veins appear as signal voids on both T1-weighted and T2-weighted spin-echo sequences and as high-signalintensity structures on gradient-echo and angiographic sequences (Fig. 4). Gadolinium-enhanced MR angiography can detect arteries and veins and differentiate between hemorrhage, intravascular thrombosis, and intravascular flow [42]. Soft-tissue AVM management is usually aimed at lesion control rather than cure, with a high risk of flare-up when surgical or endovascular removal is attempted. Low-flow vascular lesions, such as venous malforma-
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Proisy et al. tions, have a lower potential for progression. In AVMs, repeated thrombosis of the lesion may lead to coagulopathy that should be detected before delivery to prevent uncontrolled bleeding [43, 44]. Concurrently, some locations of the lesion in the lumbar or pelvic areas may prevent procedures such as lumbar puncture or vaginal delivery when lesions are located around the vaginal tract, lumbar soft tissues, or epidural space. MRI is the best modality for assessing these lesion extensions (Fig. 5). Progression of vertebral hemangioma has also been reported in the course of pregnancy, sometimes requiring surgical decompression [45, 46]. MRI is also the preferred modality in pregnancy, confirming the usual pattern of aggressive vertebral angioma [47]. Deep musculoskeletal fibromatosis—Deep musculoskeletal fibromatosis, also known as desmoid tumor, results from focal proliferation of benign fibrous tissue within muscles. Trauma and pregnancy are the main risk factors for the disease. Abdominal wall lesions are especially prevalent in women of childbearing age [48]. The role of estrogen as a growth factor for the lesion is suggested because of the increase in size of these tumors during the third trimester of pregnancy, their high prevalence in women taking birth control pills, and their tendency to regress after menopause [49]. Ultrasound is the first-line modality and shows a heterogeneous hypoechoic lesion with the muscle that has blurry margins and a possible hypervascular pattern on color Doppler imaging [50]. MRI is well suited to assessing deep extension of these lesions (Fig. 6). Lesions are usually centered in the intermuscular fascia and have the ability to invade neighboring structures, such as muscles or, more rarely, neurovascular elements, with a subsequent functional risk for the limb involved. Lesions are usually heterogeneous, including areas of collagen with typical low signal intensity and areas with more cellular content. The former areas may have a linear organization considered to be almost pathognomonic, whereas the latter areas may show various enhancements depending on the amount of vascular content [51]. Although imaging is highly suggestive of the diagnosis, biopsy is usually required for histopathologic confirmation. Rheumatoid arthritis and related diseases— The outcome of rheumatoid arthritis is typically good; symptoms improve in 75% of patients in the early stage of pregnancy despite relapse occurring in 90% of cases after delivery [52]. Complete remission is sponta-
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neously observed in between 16% and 65% of patients depending on the studies and remission definitions [53, 54], and treatment remains necessary in other cases. The evolution of spondyloarthropathies is less stereotypical. Despite controversy among existing studies, it is acknowledged that during pregnancy ankylosing spondylitis remains stable in 40% of cases, improves in 30%, and worsens in the remaining 30%. Worsening is particularly significant in patients with preexisting spinal involvement, probably due to the combined effect of mechanical and inflammatory factors [55]. Despite the lack of guidelines for imaging follow-up in pregnant women, ultrasound and MRI may be useful for monitoring rheumatoid arthritis and ankylosing spondylitis, respectively. In severe cases, imaging-guided steroid injections may be attempted. Childbirth Cephalopelvic disproportion may lead to dystocia and perinatal asphyxia. When suspected, this condition should be confirmed to plan a cesarean delivery. In this case, measurement of the pelvic brim in different planes is routinely offered to patients with risk factors. CT is currently the modality of choice compared with radiography because of the lower radiation dose and more accurate imaging [56]. MRI has also been evaluated in the past few years [57] but requires a longer examination time and involves higher cost. Apart from the risk to the fetus, vaginal delivery also exerts a high degree of stress on the mother’s pelvic brim and neighboring structures, with a subsequent risk of nerve compression and joint distention. Lumbosacral Plexopathy Lumbosacral plexopathy, also referred to as “intrapartum maternal lumbosacral plexopathy,” is a well-known delivery complication that results from compression of the lumbosacral trunk by the descending fetal head against the sacral wing [58, 59]. Patients typically report acute radiculopathy during delivery, with subsequent foot drop during the postpartum period. In a study by Katirji et al. [58], the right side was involved in six of seven cases, probably due to the higher prevalence of left occiput anterior orientation of the fetal head. Neural lesions usually recover within a few months. MRI is known to provide gross analysis of the lumbosacral plexus branches [60]. In the case of intrapartum maternal lumbosacral plexopathy, MRI can
show hypertrophy of the involved nerve roots with associated high signal intensity on T2weighted sequences, thus confirming the injury mechanism (Fig. 7). Recent advances with the use of 3D anatomic nerve-selective MR neurography based on diffusion-weighted sequences with directional encoding may help to emphasize focal impairment of the lumbosacral plexus in cases of intrapartum maternal lumbosacral plexopathy [61, 62]. The differential diagnosis of postpartum radicular or truncular deficiency includes pyomyositis or hematoma of the piriformis muscle due to prolonged labor [63, 64]. Disorders of the Symphysis Pubis Stress on the pelvic girdle that occurs during pregnancy and increases during delivery may be responsible for acute changes to the symphysis pubis. For example, widening and the presence of gas on CT may be seen frequently in the pubic symphysis in nonsymptomatic patients who have undergone an uncomplicated delivery [65]. Similarly, MRI of nonsymptomatic pelvic ring joints performed in the immediate postpartum period may reveal higher water content of the pubic cartilage and focal edematous changes to the parasymphyseal pubis bones [66]. In rare instances, load applied to the pelvic brim may exceed joint capabilities and lead to disruption and pain of the pubic symphysis. Prevalence of this complication is estimated to range between 1 in 521 and 1 in 20,000 childbirths [67]. Diastasis of the pubic bone up to 47 mm may be observed on radiographs [67] and is usually associated with various degrees of widening of the sacroiliac joints. On ultrasound, Scriven et al. [68] showed a gap larger than 10 mm as confirming the diagnosis of disruption, whereas absence of reduction was associated with persistence of symptoms over time for one patient. MRI may show fluid within the symphysis pubis [69]. Treatment is usually conservative [67, 70]. Sacrococcygeal Dislocation and Coccygodynia Coccygodynia is defined as pain in the coccyx area occurring in the sitting position [71]. Childbirth is a common cause, estimated to explain 7.3% of chronic coccygodynia in women [71]. Difficult deliveries and a short perineum are the two main risk factors for this condition [71]. Symptoms usually arise the day after delivery as soon as the patient adopts a sitting position [71]. Abnormalities in the area of the sacrococcygeal joint
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Musculoskeletal Disorders in Pregnancy may be evaluated with static and dynamic lateral radiography in the standing and sitting positions [72] (Fig. 8). The coccyx may be considered rigid when fused with the sacrum, normal when flexion or extension on dynamic radiography remains between 5° and 25°, hypermobile when it is above 25° flexion, or dislocated when translated backward [73]. Dislocation and severe hypermobility (above 35°) are typically associated with symptoms [74]. Although normal mobility and hypermobility are often encountered, posterior dislocation of the coccyx appeared to be specifically related to childbirth compared with an age-matched control group [71]. In far more rare instances, a true fracture of the coccyx or fifth sacral vertebra may occur and lead to pseudarthrosis [71]. In a recent study, MRI was recommended as a second-line modality when radiography fails to provide an adequate explanation for symptoms. Despite the lack of a control group, the authors suggested that intraosseous edema or changes to the soft tissue surrounding the sacrococcygeal joint may reflect a source of pain [75]. Postpartum Early Postpartum Apart from pain resulting from the previously mentioned articular or neural trauma, the early postpartum period may see the occurrence of additional disorders related to childbirth, such as maternal infection and, later on, specific abnormality of the mother’s wrist due to baby care. Septic arthritis—Despite being a rare condition, infectious sacroiliitis may be related to delivery and occur in the early postpartum period [76–78]. Hematogenous contamination of the joint results from a simple injury to the genital tract and may coexist with urinary tract infection or endometritis; Staphylococcus aureus is the most prevalent organism encountered [76]. Because of the high prevalence of nonspecific lumbar pain and inconsistent presence of clinical and biologic signs of inflammation in the postpartum period, MRI should be performed as soon as the diagnosis is suspected. Involvement is typically unilateral, with inflammatory signs in both subchondral bone and neighboring soft tissues [79] (Fig. 9). Other reported pelvic infections in the postpartum period include piriformis muscle abscess resulting from a direct forceps injury [64] and osteomyelitis of the pubic symphysis [80].
Baby wrist—Wrist overuse associated with baby care in the postpartum period is known to cause de Quervain tenosynovitis [1, 3]. In a study by Anderson et al. [81], de Quervain tenosynovitis occurred an average of 8 months after childbirth and was associated with the height and weight of babies above the 95th percentile, emphasizing the role of mechanical stress. However, in some instances, association with carpal tunnel syndrome during pregnancy suggests the contribution of hormonal changes to the disease [82]. MRI can confirm thickening of the first compartment tendons and surrounding tissues with hyperintensity on T2weighted sequences. Ultrasound can confirm the diagnosis, is more readily available and affordable, and has a similar accuracy to MRI [83]. Symptoms usually resolve with rest and conservative treatment; however, local steroid injections are known to offer better results in pregnant women than in the general population [84, 85]. Late Postpartum Paraglenoid sulcus—Paraglenoid sulcus is a groove in the iliac bone adjacent and lying parallel to the inferior sacroiliac joint. This finding is routinely used for sex determination in forensic and anthropologic practice [86]. In a study by Dee [87], a typical paraglenoid sulcus was found in 25% of women. In men, sulci are considered to be less prevalent (6% of patients in the study by Dee), more shallow [88, 89], and associated with a triangular-shaped pelvic brim [87]. From a pathophysiologic viewpoint, paraglenoid sulcus is understood to result from traction of the inferior part of the ventral sacroiliac ligament at its site of attachment to the iliac bone (Fig. 10). Anatomic works have shown this ligament to insert on the iliac wing a few millimeters lateral to the sacroiliac joint, a site that precisely hosts the paraglenoid sulcus [90]. Despite controversy [91], this finding is considered by some authors to represent a marker of pregnancy and parturition [89, 92], particularly when the groove is deep [93]. This finding is easily recognized on anterior radiographs of the pelvis (Fig. 11). Analysis with CT excluded the theory that paraglenoid sulcus represents a vascular channel for hypogastric vessels [93], which was advanced in a former study [94]. Osteitis condensans ilii—Osteitis condensans ilii is an area of bone sclerosis arising on the inferior aspect of the iliac bone adjacent to
the sacroiliac joint and occurring bilaterally in 76–87% of cases [95, 96]. A more recent study using CT has shown the sacral bone to be involved by sclerosis in some cases [97]. This condition has been associated with low back pain, tenderness of the sacroiliac joint [96], paraglenoid sulcus, and increased lumbar lordosis [93]. Its prevalence remains low, estimated at between 0.9% and 2.5% of the general population [98]. Numerous studies have shown high prevalence of osteitis condensans ilii in women with previous pregnancies [95, 99, 100]. Nevertheless, other works have suggested that pregnancy is not an exclusive risk factor for osteitis condensans ilii because this finding is sometimes reported in men with high physical activity [101] and nulliparous women [100]. When followed, osteitis condensans ilii has been shown to be reversible over time in up to 76% of cases [95]. Residual joint pain and associated remodeling—As mentioned previously, lumbar spine, sacroiliac, pubic symphysis, and sacrococcygeal joints may, in rare instances, remain symptomatic [67, 71]. In the pubic symphysis, degenerative articular cysts have rarely been considered to result from childbearing [102–104]. When the lesion develops posteriorly, it may impinge on the urinary tract and cause dysuria [103]. MRI can confirm the diagnosis and depict deep extension of the lesion [102]. Assessment with ultrasound and CT has also been reported [105]. Conclusion Musculoskeletal disorders related to pregnancy mainly result from overload and occur during the childbearing period and delivery. Nevertheless, this transient period of life may lead to ongoing disorders or morphologic changes on imaging that require detailed understanding and accurate diagnosis by radiologists. References 1. Ritchie JR. Orthopedic considerations during pregnancy. Clin Obstet Gynecol 2003; 46:456–466 2. Sax TW, Rosenbaum RB. Neuromuscular disorders in pregnancy. Muscle Nerve 2006; 34:559–571 3. Heckman JD, Sassard R. Musculoskeletal considerations in pregnancy. J Bone Joint Surg Am 1994; 76:1720–1730 4. Musielak-Zanetti C, Flipo RM, Cotten A. Quelle imagerie au cours de la grossesse? Rev Rhum Ed Fr 2005; 72:750–754 5. Wu WH, Meijer OG, Uegaki K, et al. Pregnancyrelated pelvic girdle pain (PPP). I. Terminology,
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Fig. 1—32-year-old woman with stress fracture of right femoral head. Patient reported rapidly progressing right hip pain occurring at 8 months of pregnancy. A, Coronal fat-saturated T2weighted MR image obtained during early postpartum period shows joint effusion (arrowhead) and subtle low-signal-intensity linear image parallel to subchondral bone of right femoral head, corresponding to fracture line (arrow). Enlarged uterus is also visible (asterisk). B, Sagittal fat-saturated T2weighted MR image of right hip also shows fracture line (arrow).
A
B
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Fig. 2—36-year-old woman with bilateral transient osteoporosis of femoral heads. Pain initially occurred on left hip after seventh month of pregnancy, followed by contralateral side 3 weeks later. A, Coronal fat-saturated T2-weighted MR image obtained during early postpartum period shows enlarged uterus (asterisk), bilateral bone marrow edema of femoral heads (arrowheads), and joint effusion (arrows). B, Bone marrow edema is also seen on coronal T1-weighted MR image as slight low signal intensity of femoral heads with no fracture or osteonecrosis line.
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Musculoskeletal Disorders in Pregnancy
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Fig. 3—29-year-old woman who presented with meralgia paresthetica of right thigh during ninth month of pregnancy. A, Short-axis ultrasound images over anterior superior iliac spine (ASIS) show ilioinguinal ligament (arrowheads) and swelling and hypoechogenicity of right lateral femoral cutaneous nerve (arrows) when compared with contralateral side. B, Long-axis ultrasound image over right lateral femoral cutaneous nerve at level of anterior superior iliac spine shows pathologic features in longitudinal plane on right side (arrows). Proximal portion of nerve (arrowheads) is normal and tiny.
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Fig. 4—30-year-old woman with frontal soft-tissue arteriovenous malformation. A, Photograph shows slight swelling of right forehead since childhood that rapidly enlarged during first pregnancy. B, Sagittal 3D angio-MR image of head and neck shows abnormal frontal number of vessels (arrow) with arterial afferences.
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Fig. 5—30-year-old woman with previously known giant venous malformation of right lower limb and pelvis. A, Axial fat-saturated T2-weighted MR image shows fetal head (arrowhead) and venous malformation (arrows). B, Axial fat-saturated T2-weighted MR image shows venous malformation located on right genital tract (arrow), contraindicating vaginal delivery. (Fig. 5 continues on next page)
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Fig. 5 (continued)—30-year-old woman with previously known giant venous malformation of right lower limb and pelvis. C, Sagittal fat-saturated T2-weighted MR image emphasizes lumbar venous malformation (arrow) that contraindicates epidural anesthesia under L3 vertebra level.
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Fig. 6—30-year-old woman with pathologically proven desmoid tumor of right thigh, with history of rapidly progressing lump during ninth month of pregnancy. A, Coronal STIR MR image shows heterogeneous tumor of right thigh (arrows) including peripheral content with low signal intensity (arrowhead). B, Axial T1-weighted MR image confirms lesion centered underneath (arrows) and within vastus lateralis muscle (asterisk). Low-signal-intensity content is also depicted (arrowhead). C, T1-weighted fat-saturated gadolinium-enhanced MR image in axial plane shows brisk enhancement of central portion of lesion, confirming its cellular and vascular content.
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Musculoskeletal Disorders in Pregnancy Fig. 7—33-year-old woman with acute L5 radiculopathy during delivery and subsequent foot drop and sensory loss. Electrodiagnosis confirmed L5 root impairment. Symptoms progressively resolved within 6 months. A, Axial T1-weighted MR image shows hypertrophy of right L5 root compared with contralateral side (circles). B, Coronal STIR MR image shows spontaneous hyperintensity of right L5 root compared with contralateral side (arrows).
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Fig. 8—38-year-old woman with persistent coccygodynia 18 months after vaginal delivery. A, Lateral radiograph obtained in standing position shows posterior subluxation of sacrococcygeal joint. B, Lateral radiograph obtained in sitting position shows dislocation of coccyx.
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Proisy et al. Fig. 9—31-year-old woman with right postpartum sacroiliitis. Right gluteal pain started few days after normal delivery. CT-guided biopsy confirmed presence of gram-positive cocci. A, Oblique axial STIR MR image shows enlarged postpartum uterus (asterisk) and increased subchondral signal intensity on both aspects of right sacroiliac joint (arrow). B, Oblique coronal STIR MR image also shows subchondral osteitis of joint (arrow).
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Fig. 10—Asymptomatic 56-year-old woman. Axial T2-weighted MR image shows anatomy of normal ventral sacroiliac ligament (arrows) as thin linear structure traversing sacroiliac joint anteriorly. Insertion of ligament on iliac bone lateral to joint is visible.
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Fig. 11—47-year-old multiparous woman with lumbar pain. Anteroposterior radiograph of pelvis incidentally shows bilateral deep grooves on outer edges of sacroiliac joints (arrows), corresponding to typical paraglenoid sulci.
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