Time course of the effects of cervical epidural anesthesia on pulmonary function

Background and Objectives. During cervical epidural anesthesia the C4, C5, and sometimes C3 nerve roots are anesthetized. One might therefore expect pulmonary compromise due to the block of the phrenic nerve if anesthesia extends to C3. This study was conducted to measure the effects of cervical epidural anesthesia using 2% lidocaine on pulmonary function, with specific attention given to the time course of pulmonary changes in relation to spread of analgesia. Methods. Fifteen adult patients without preexisting lung disease undergoing carotid endarterectomy, breast surgery, or cervical epidural steroid injection were enrolled. Cervical epidural anesthesia was performed at the C7–T1 interspace using 300 mg lidocaine with epinephrine. Pulmonary function, including forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), maximum inspiratory pressure (MIP), and SpO₂ while breathing room air were measured prior to and 5, 10, 20, and 40 minutes after lidocaine injection. Results. Analgesia to pinprick reached median dermatomes of C3 to T8 (range: C2–T12) by 20 minutes after lidocaine injection. FEV₁ and FVC decreased approximately 12–16% between 20 and 40 minutes after injection. Maximum inspiratory pressure and SpO₂ did not significantly change. Conclusions. Cervical epidural anesthesia using 300 mg lidocaine results in measurable reduction in bedside pulmonary functions concomitant with the spread of analgesia to the C3 dermatome. These changes were complete 20 minutes after lidocaine injection. In patients without preexisting lung disease, these changes were not clinically significant, except in one patient. We conclude that motor block of the phrenic nerve is incomplete under the conditions of this study.     

Epidural anesthesia in a patient with myasthenia gravis

We present a patient with myasthenia gravis who was safely managed by epidural anesthesia during and after thymectomy. An epidural catheter was inserted via the C7-T1 intervertebral space and 2% lidocaine was used during the surgery. The level of analgesia as determined by pinprick extending from C5 to T6. Epidural morphine or morphine and bupivacaine were used for postoperative pain relief. We evaluated ventilatory responses to CO₂ and hypoxia after epidural anesthesia with lidocaine or morphine, and during continuous epidural infusion of the mixture of morphine and bupivacaine. Ventilatory responses to CO₂ and hypoxia were both depressed following epidural injection of morphine. However, depression of ventilatory responses was not demonstrated following continuous epidural infusion of a mixture of morphine and bupivacaine. This case report suggests that epidural anesthesia is useful as a primary anesthetic and for postoperative pain control in patients with myasthenia gravis.     

Spinal cord ischemia following thoracotomy without epidural anesthesia

PURPOSE: Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. CLINICAL FEATURES: A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5-6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5-6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. CONCLUSION: In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.     

Thermoregulatory effects of spinal and epidural anesthesia during cesarean delivery

Background and Objectives: Hypothermia is likely to develop faster during spinal anesthesia than epidural anesthesia. A natural consequence of the rapid temperature decrease during spinal anesthesia is that the shivering threshold will be reached sooner and that more shivering will be required to prevent further hypothermia. We tested the hypotheses that the onset of hypothermia is more rapid and the onset and intensity of shivering earlier during spinal than epidural anesthesia. Methods: Patients undergoing cesarean delivery were randomly assigned to spinal anesthesia or epidural anesthesia. Spinal anesthesia was induced by injecting 2 mL 0.5% dibucaine into the L4–L5 interspace. Epidural anesthesia was induced with 20 mL 2% mepivacaine injected into the L2–L3 interspace. Thermal comfort and shivering were scored by a blinded observer. Results: Fifteen patients given each type of anesthesia had upper sensory levels ≥T4 dermatome. Sensation was entirely absent from the leg during spinal anesthesia, but lower block levels were near S5 during epidural anesthesia. Tympanic membrane temperatures initially decreased faster during spinal anesthesia, but subsequently decreased at a rate of 0.5°C/h in both groups. The onset and incidence of shivering (detected qualitatively) did not differ significantly between the two groups, but shivering intensity was significantly reduced during spinal anesthesia. Furthermore, the shivering thresholds were 36.4 ± 0.3°C (mean ± SD) during spinal anesthesia versus 37.1 ± 0.4°C in those given epidural anesthesia (P = .006). There were no clinically important differences in thermal comfort with the two kinds of neuraxial anesthesia. Conclusions: We failed to confirm our hypothesis, but for an unexpected reason: Thermoregulation was impaired more by spinal anesthesia than epidural anesthesia. It seems likely that in our patients spinal anesthesia inhibited thermoregulatory control more than epidural anesthesia because it better blocked sensory input from the legs.     

Epidural hematoma following epidural catheter placement in a patient with chronic renal failure

PURPOSE: We report a case of epidural hematoma in a surgical patient with chronic renal failure who received an epidural catheter for postoperative analgesia. Symptoms of epidural hematoma occurred about 60 hr after epidural catheter placement. CLINICAL FEATURES: A 58-yr-old woman with a history of chronic renal failure was admitted for elective abdominal cancer surgery. Preoperative laboratory values revealed anemia, hematocrit 26%, and normal platelet, PT and PTT values. General anesthesia was administered for surgery, along with epidural catheter placement for postoperative analgesia. Following uneventful surgery, the patient completed an uneventful postoperative course for 48 hr. Then, the onset of severe low back pain, accompanied by motor and sensory deficits in the lower extremities, alerted the anesthesia team to the development of an epidural hematoma extending from T12 to L2 with spinal cord compression. Emergency decompressive laminectomy resulted in recovery of moderate neurologic function. CONCLUSIONS: We report the first case of epidural hematoma formation in a surgical patient with chronic renal failure (CRF) and epidural postoperative analgesia. The only risk factor for the development of epidural hematoma was a history of CRF High-risk patients should be monitored closely for early signs of cord compression such as severe back pain, motor or sensory deficits. An opioid or opioid/local anesthetic epidural solution, rather than local anesthetic infusion alone, may allow continuous monitoring of neurological function and be a prudent choice in high-risk patients. If spinal hematoma is suspected, immediate MRI or CT scan should be done and decompressive laminectomy performed without delay.     

Paraplegia after combined general and epidural anesthesia: a case report

Neurological complications after epidural anesthesia performed for abdominal surgery are uncommon, but of important consequence with significant morbidity. Paraplegia is very rare and may be a result of multiple factors. We report a case of elective colectomy under combined general and epidural anesthesia for a carcinoma. An epidural infusion was used for intra-operative and post-operative analgesia. During induction of anesthesia, the patient was asystolic for a few seconds and during the first postoperative day, a hypotensive episode was registered. He then developed a sensory-motor deficit in the legs. A spinal cord infarction at the level of T10 extending to T2 was diagnosed with magnetic resonance imaging. The association of hypotension as a cause of spinal cord infarction is discussed. The factors that may have contributed to paraplegia and preventive neuroprotective strategies are reviewed.     

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial

BACKGROUND CONTEXTLength of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery.PURPOSEThis study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection.DESIGNA randomized single-blinded controlled study.PATIENT SAMPLEThirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected.OUTCOME MEASURESLOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded.METHODSPatients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11–T12 or T12–L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine.RESULTSThere were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups.CONCLUSIONSCombined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.     

A comparative study of general anesthesia versus combined spinal–epidural anesthesia on the fetus in cesarean section

BackgroundObstetric anesthesia guidelines recommend regional over general anesthesia for most caesarean sections to decrease the risk for both fetus and mother.Aim of the workTo determine the effects of combined spinal epidural anesthesia and general anesthesia on the newborns and the mother undergoing elective cesarean section.SubjectsA total of 60 consecutive women with uncomplicated singleton pregnancies at term and scheduled to undergo elective cesarean section at Kasr Al-Aini obstetric hospital participated in this prospective study. The women were divided into 2 groups (each 30), a general anesthesia group (A) and combined spinal–epidural anesthesia group (B).MethodsUmbilical artery blood gas analysis and Apgar scores were assessed at 1 and 5 min after delivery in the newborn while systolic and diastolic blood pressure, heart rate, oxygen saturation and (capnography in general anesthesia) were measured preoperative and after 5, 10 and 15 min of induction of anesthesia in the mothers. In addition, the time from induction of anesthesia till delivery of the fetus and duration in operative room were measured.ResultsApgar score recorded statistically significant differences between the 2 groups at 1 min and 5 min, where with combined spinal–epidural anesthesia the Apgar score readings were higher than with general anesthesia. HCO₃ readings showed a statistically significant difference between the 2 groups after 1 and 5 min, where the newborns in general anesthesia group had a statistically significant lower HCO₃ compared to the newborns in combined spinal–epidural group. Patients in general anesthesia group were significantly more tachycardic compared to patients in combined spinal–epidural group.ConclusionCombined spinal–epidural anesthesia is safer on the newborn than general anesthesia regarding the APGAR scores and acid–base balance.     

Disseminated Staphylococcus aureus infection following spinal anesthesia: a case report

We here presented a 65-year-old woman with disseminated Staphylococcus aureus infection following spinal anesthesia. The patient underwent spinal anesthesia for great saphenous vein stripping. Twenty days after the procedure, the patient developed hydrocephalus, pulmonary infection, and epidural abscess. Microbiological culture of the pus showed infection by S aureus. Appropriate antibiotic therapy and prompt surgical abscess drainage were associated with good outcome. Hydrocephalus is thought to be associated with arachnoiditis caused by S aureus infection, which provides new insights into the pathophysiology of arachnoiditis. Here we reported a case of disseminated S aureus infection following spinal anesthesia, implicating that appropriate interventions should not be delayed for waiting for the microbiological results.     

Effects of abdominal surgery on somatosensory evoked potentials during nitrous oxide-enflurane anesthesia

The effect of abdominal surgery on median nerve somatosensory evoked potentials (SEPs) was studied in 8 enflurane and nitorous oxide anesthesia (GOE) patients. We further compared the effect of epidural anesthesia. The first recording was done immediately prior to induction. Anesthesia was then induced with 5mg·kg^–1 i.v. of thiopental and maintained with 1.0% enflurane, 66% N₂O and 33% O₂. Before skin incision for abdominal surgery, the second recording was performed under GOE anesthesia and the third recording during surgery. Then 2% lidocaine was injected into the epidural space through a preinserted catheter, and after 15min the fourth recording was obtained. The latencies of peaks N1, P2 and N2 and the amplitudes of N1-P2 and P2-N2 were measured. The latencies of N1, P2 and N2 increased and the amplitudes of N1-P2 and P2-N2 deceased significantly after the induction of anesthesia compared with the control values. During abdominal surgery the latencies of N1 and P2 decreased and the amplitudes of N1-P2 and P2-N2 increased. After epidural anesthesia, however, the latencies of N1 and P2 increased and the amplitudes of N1-P2 and P2-N2 decreased significantly and returned almost to the values recorded under preoperative GOE anesthesia. These phenomena indicated that the excitations produced by surgical stimulation in nerve ending might have been transmitted to the central nervous system via spinal nerves and blocked by epidural anesthesia.(Kasaba T, Kosaka Y: Effects of abdominal surgery on somatosensory evoked potentials during oxide-enflurane anesthesia. J Anesth 5: 281–286, 1991)     

Use of high-resolution thermography as a validation measure to confirm epidural anesthesia in mice: a cross-over study

BackgroundEffective epidural anesthesia is confirmed in humans by sensory assessments but these tests are not feasible in mice. We hypothesized that, in mice, infrared thermography would demonstrate selective segmental warming of lower extremities following epidural anesthesia.MethodsWe anesthetized 10 C57BL/6 mice with isoflurane and then inserted a PU-10 epidural catheter under direct surgical microscopy at T11-12. A thermal camera (thermal sensitivity ±0.05°C, pixel resolution 320x240 pixels, and spatial resolution 200 μm) recorded baseline temperature of front and rear paws, tail and ears. Thermography was assessed at baseline and 2, 5, 10, and 15 min after an epidural bolus dose of 50 μL bupivacaine 0.25% or 50 μL saline (control) using a cross-over design with dose order randomized and investigators blinded to study drug. Thermal images were recorded from video and analyzed using FLIR software. Effect over time and maximal effect (E_max) were assessed by repeated measures ANOVA and paired t-tests. Comparisons were between bupivacaine and control, and between lower vs upper extremities.ResultsEpidural bupivacaine caused progressive warming of lower compared with upper extremities (P <0.001), typically returning to baseline by 15 min after administration. Mean (±SD) E_max was +3.73 (±1.56) °C for lower extremities compared with 0.56 (±0.68) °C (P=0.03) for upper extremities. Following epidural saline, there was no effect over time (E_max for lower extremities −0.88 (±0.28) °C compared with the upper extremities −0.88 (±0.19) °C (P >0.99).ConclusionsThermography is a useful tool to confirm epidural catheter placement in animals for which subjective, non-noxious, sensory measures are impossible.     

Hemodynamic effects of oral clonidine premedication in lumbar epidural anesthesia

Clonidine, an α₂-adrenergic agonist, has a potent sympatholytic effect and augments the pressor effect of ephedrine during general anesthesia. We evaluated whether oral clonidine premedication would alter the hemodynamic changes and enhance the pressor response to intravenous ephedrine during epidural anesthesia in 35 adult patients. They were randomly administered either premedication with clonidine approximately 5 μg·kg⁻¹ po (n=17) or no clonidine medication (n=18). After establishment of epidural anesthesia, the hemodynamic response to ephedrine iv was measured in the awake state at 1-min intervals for 10 min. Then, the same hemodynamic measurement was repeated in the asleep state induced with midazolam iv. There were no differences in blood pressure (BP) and heart rate values between groups during the onset of epidural anesthesia, except that BP before epidural anesthesia was lower in the clonidine group than the control group (P<0.05). The magnitude and duration of pressor responses to ephedrine were comparable between groups in awake and asleep states. In conclusion oral clonidine premedication 5 μg·kg⁻¹ alters neither the hemodynamic changes nor the pressor response to intravenous ephedrine during epidural anesthesia. Presented at the Annual Meeting of the Japan Society for Clinical Anesthesia, Oita City, Oita, November, 1994     

Epidural anesthesia and pulmonary function

The epidural administration of local anesthetics can provide anesthesia without the need for respiratory support or mechanical ventilation. Nevertheless, because of the additional effects of epidural anesthesia on motor function and sympathetic innervation, epidural anesthesia does affect lung function. These effects, i.e., a reduction in vital capacity (VC) and forced expiratory volume in 1 s (FEV_1.0), are negligible under lumbar and low thoracic epidural anesthesia. Going higher up the vertebral column, these effects can increase up to 20% or 30% of baseline. However, compared with postoperative lung function following abdominal or thoracic surgery without epidural anesthesia, these effects are so small that the beneficial effects still lead to an improvement in postoperative lung function. These results can be explained by an improvement in pain therapy and diaphragmatic function, and by early extubation. In chronic obstructive pulmonary disease (COPD) patients, the use of thoracic epidural anesthesia has raised concerns about respiratory insufficiency due to motor blockade, and the risk of bronchial constriction due to sympathetic blockade. However, even in patients with severe asthma, thoracic epidural anesthesia leads to a decrease of about 10% in VC and FEV_1.0 and no increase in bronchial reactivity. Overall, epidural administration of local anesthetics not only provides excellent anesthesia and analgesia but also improves postoperative outcome and reduces postoperative pulmonary complications compared with anesthesia and analgesia without epidural anesthesia.     

Isolated extraosseous epidural myeloma presenting with thoracic compressive myelopathy

Background contextMultiple myeloma is the commonest primary malignancy of the spine, but it rarely presents as an extraosseous epidural tumor with only five cases reported in literature so far.PurposeThe purpose of this study was to heighten awareness and treatment options of a rare case of extraosseous epidural myeloma.Study designThe study design comprises a case report and literature review.MethodsWe present a 60-year-old lady with progressive paraplegia (American Spinal Injury Association grade C) with sensory blunting below T8 level of 2 months’ duration. Magnetic resonance imaging showed an extradural tumor in the dorsal epidural space from T6 to T7 without local bony involvement. She underwent a T6 and T7 laminectomy, T5–T8 pedicle screw instrumentation, and gross total resection of tumor. Histopathological diagnosis was consistent with myeloma. After surgery, the patient underwent local irradiation and adjuvant chemotherapy.ResultsNeurological improvement of one grade (American Spinal Injury Association grade C to D) was observed at 3 weeks postoperatively.ConclusionsIsolated extraosseous epidural myeloma without destruction or collapse of vertebral bodies should be included in the differential diagnosis of epidural mass lesions causing spinal cord compression. The overall prognosis in terms of survival is poor, but early decompression can prevent neurological deterioration and improve quality of life.     

Paraplegia after epidural anesthesia in a patient with peripheral vascular disease: case report and review of the literature with a description of an original technique for hematoma evacuation

Epidural hematoma after epidural anesthesia is a rare and uncommon complication in patients with peripheral vascular disease who require perioperative anticoagulation therapy. A low index of suspicion makes its diagnosis difficult and often delayed. Treatment usually involves extensive laminectomy, increasing the chances for patient complications. In this article, the authors report a case of epidural hematoma with secondary paraplegia after epidural anesthesia. Also described is an original technique for evacuating the epidural space.     

A clinical comparison between needle-through-needle and double-segment techniques for combined spinal and epidural anesthesia

Background and Objectives. The goal of the present investigation was to compare the double-segment and the needle-through-needle techniques for combined spinal and epidural anesthesia (CSE) in a prospective, randomized, blinded study. Methods. With Ethical Committee approval and patient's consent, 120 patients were randomized to receive CSE by the needle-through-needle (SST; n = 60) or the double-segment technique (DST; n = 60). A blind observer measured the time required from skin disinfection to readiness for surgery (loss of pinprick sensation up to T10), failure of dural puncture, need for epidural top-up before surgery, patient acceptance, and occurrence of complications. Results. No neurologic complications were observed in either group. Time to readiness for surgery was 22.7 ± 8.2 minutes in the SST group and 29.8 ± 8.31 minutes in the DST one (P < .001). Dural puncture was unsuccessful in three patients in the SST group (5%) and in one patient in the DST group (1.6%) (ns); inadequate spread of spinal anesthesia was observed in five patients in the SST group (8.3%) and in eight patients in the DST group (13.3%) (ns). No difference in the incidence of hypotension, postdural puncture headache, and back pain was observed between the two groups. Acceptance of anesthetic procedure was better in the SST (85%) than in the DST group (66.6%) (P < .05). Conclusions. The needle-through-needle technique for CSE requires less time, has no greater failure rate, and results in greater patient satisfaction than the double-segment technique. The use of a spinal needle with an adjustable locking mechanism and protruding up to 15 mm beyond the Tuohy needle improved successful spinal block in the needle-through-needle technique compared with previous reports.     

Complete paraplegia as a result of regional anesthesia

Complications after spinal or epidural anesthesia are rare. We report 2 cases of postoperative, complete paraplegia after regional anesthesia in orthopaedic patients not on anticoagulants. The paralysis was likely the result of spinal cord compression secondary to an epidural hematoma in 1 case and subdural hematoma in 1 case. A review of the literature regarding complications of regional anesthesia is presented. Regional anesthesia should be administered with caution and in selected patients.     

Epidural inflammatory pseudotumor in the thoracic spine in a patient with polymyalgia rheumatica

Background contextOnly six previous cases of epidural inflammatory psedotumor in the spine have been reported. None of them were seen in the course of polymyalgia rheumatica (PMR).PurposeTo describe a rare case of epidural inflammatory pseudotumor in the thoracic spine in a patient with PMR.Study designCase report.MethodsA 63-year-old man had a 6-year history of PMR treated with prednisone and cyclosporine. He presented with gait disturbance. Magnetic resonance imaging on the 12th day after the onset of the symptoms showed spinal cord compression caused by a posterior epidural mass at the T5–T6 level.ResultsThe patient underwent a T5–T6 laminectomy and a total excision of the mass, which involved the ligament flavum and epidural adipose tissue and firmly attached to the dura mater. Histopathologic examination revealed severe lymphoplasmacytic infiltration with fibrosis in the entire specimen and no evidence of hematomas or tumorous lesions. After surgery, the patient's neurologic symptoms disappeared immediately. Two years after surgery, the patient is neurologically normal and has not had a recurrence.ConclusionsThis report identifies a rare case of epidural inflammatory pseudotumor in the thoracic spine in a patient with PMR.     

Epidural anesthesia as a novel anesthetic technique for anterior lumbar interbody fusion

Study ObjectiveTo determine if epidural anesthesia is a reasonable technique for anterior lumbar interbody fusion.DesignRetrospective chart review.SettingAcademic university hospital.MeasurementsThe charts of patients who underwent an anterior lumbar interbody fusion between January 1, 2001 and November 1, 2008 were reviewed. A total of 102 consecutive patients, of whom 19 received an epidural and 83 underwent general anesthesia, met inclusion criteria. Postoperative pain, nausea, opioid administration, operating room time, anesthesia time, Postanesthesia Care Unit (PACU) time, and total hospital time were compared.Main ResultsIn the PACU, patients receiving epidural anesthesia showed reductions in median immediate [numerical rating scale (NRS) 0 vs 7; P < 0.001] and peak (NRS 4 vs 8; P = 0.001) postoperative pain scores, and postoperative mean arterial pressure (69.7 vs 90.3; P < 0.001). Epidural anesthesia patients also needed significantly less intravenous morphine-equivalent medication both intraoperatively (5 vs 29; P < 0.001) and postoperatively (3.34 vs 10; P = 0.021).ConclusionsEpidural anesthesia for anterior lumbar interbody fusion is potentially beneficial compared with general anesthesia, showing improved perioperative pain control.     

Epidural hematoma after spinal anesthesia in a patient with undiagnosed epidural lymphoma

The incidence of hemorrhagic complications after neuroaxial anesthesia is very infrequent. We report a case of a woman developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia at the lumbar level L3-4 for removal of a wire loop in her left knee. No hemostasis altering medication had been taken before and after spinal puncture. The hematoma presenting at the lumbar level L2-3 had to be removed via laminectomy. Pathological examination of the hematoma revealed a highly vascularized centroblastic non-Hodgkin's lymphoma that was not diagnosed before surgery. The patient did not develop any neurological deficits. IMPLICATIONS: We report a case of a women developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia for removal of a wire loop in her left knee. Pathological examination of the neurosurgically removed hematoma revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma.