title: Interscapular pain associated with neuraxial labour analgesia: a case series.
abstract: OBJECTIVE
  Some labouring women with neuraxial labour analgesia experience severe upper back pain, typically between the scapulae. This pain may complicate management of neuraxial analgesia/anesthesia, and it may also have important implications for the mode of delivery. This case series describes the clinical course and management of three patients who developed interscapular pain associated with neuraxial labour analgesia.
  
  
  RESULTS
  Neuraxial labour analgesia was initiated in all patients with a combined spinal-epidural technique and maintained via patient-controlled epidural analgesia. Two patients were nulliparous. One patient experienced interscapular pain during initiation of epidural anesthesia for Cesarean delivery after 19 hr of maintenance of labour analgesia with local anesthetic/opioid solution. The other two patients experienced interscapular pain during routine maintenance of epidural labour analgesia. In two patients, the epidural space was identified using loss of resistance to air. Another patient recalled experiencing interscapular pain with her prior labour epidural. Management of these patients included decreasing the epidural infusion rate, increasing the concentration of local anesthetic in the epidural infusion solution, administration of epidural opioids, and replacement of the epidural catheter. All patients eventually experienced relief of their interscapular pain.
  
  
  CONCLUSIONS
  While little is understood about the etiology of this unique anesthetic complication, it may have important clinical consequences, including inadequate analgesia, inability to provide timely epidural anesthesia, and an increased risk of Cesarean delivery. Future work should characterize at-risk patients, delineate effective treatment strategies, and identify any associated long-term consequences.
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, IL, USA. tklumpnerauthor@gmail.com.|Department of Anesthesiology, University of Michigan, 1H247 University Hospital, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5048, USA. tklumpnerauthor@gmail.com.
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Klumpner
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Paloma
authors.initials: P
authors.lastname: Toledo
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Cynthia A
authors.initials: CA
authors.lastname: Wong
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Jason R
authors.initials: JR
authors.lastname: Farrer
mesh_terms: D000293:Adolescent; D000328:Adult; D015360:Analgesia, Epidural / Q000009:adverse effects*; D016362:Analgesia, Obstetrical / Q000009:adverse effects*; D001416:Back Pain / Q000209:etiology*; D005260:Female; D006801:Humans; D011247:Pregnancy; D012540:Scapula