Extensive cervical prevertebral haemorrhage with airway obstruction after low-energy hyperextension injury

A 45-year-old man developed a massive prevertebral cervical haematoma after a low-energy hyperextension trauma with an anterior teardrop fracture of the C4 vertebra. He required urgent nasotracheal intubation because of acute respiratory obstruction. During surgical removal of the haematoma, a small segmental artery arising from the vertebral body of C4 was identified as the source of the bleeding. The anterior longitudinal ligament was intact. The patient recovered uneventfully and was discharged six days after surgery without neurological sequelae.Large prevertebral retropharyngeal hematomas in non-geriatric patients after low-energy cervical hyperextension injury are very rare, especially when the discoligamentary structures are intact. This is, to our knowledge, the first report of a small segmental artery being identified as the source of acute bleeding in such circumstances. The treatment team must be alert to the possibility of a prevertebral haematoma when dyspnoea and dysphonia arise a short time after a cervical hyperextension injury, even in cases of low-energy trauma.     

Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following ‘normal’ neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.     

Regional anaesthesia in patients taking anticoagulant drugs

Many surgical patients are taking drugs that impair normal coagulation, and this causes concern about the risk of perioperative bleeding events. The anaesthetist is particularly concerned about compressive vertebral canal haematomas that may occur after spinal or epidural anaesthetic techniques. Fortunately, the risk of this complication is very low. The major risk factors are coagulopathy or technical difficulties with the block. There is also concern about perineural haematomas that may be associated with peripheral nerve blocks. This article attempts to put the risks of these complications into context, with reference to different classes of anticoagulant drugs.     

Regional anaesthesia in patients taking anticoagulant drugs

Many surgical patients are taking drugs that impair normal coagulation, and this causes concern about the risk of perioperative bleeding events. The anaesthetist is particularly concerned about compressive vertebral canal haematomas, which may occur after spinal or epidural anaesthetic techniques. Fortunately, the risk of this complication is very low. The major risk factors are coagulopathy or technical difficulties with the block. There is also concern about perineural haematomas, which may be associated with peripheral nerve blocks. This article attempts to put the risks of these complications into context, with reference to different classes of anticoagulant drugs.     

Regional anaesthesia in patients taking anticoagulant drugs

Many surgical patients are taking drugs that impair normal coagulation, and this causes concern about the risk of perioperative bleeding events. The anaesthetist is particularly concerned about compressive vertebral canal haematomas, which may occur after spinal or epidural anaesthetic techniques. Fortunately, the risk of this complication is very low. The major risk factors are coagulopathy or technical difficulties with the block. There is also concern about perineural haematomas, which may be associated with peripheral nerve blocks. This article attempts to put the risks of these complications into context, with reference to different classes of anticoagulant drugs.     

Is anticoagulation and central neural blockade a safe combination?

The indiscriminate insertion of epidural or subarachnoidal needles or catheters in patients who are anticoagulated or are about to be anticoagulated carries the inherent risk of the potential development of a compressing vertebral canal haematoma, which may severely jeopardize the patient's (quality of) life. Although the isolated use of aspirin or non-steroidal anti-inflammatory drugs in general is no longer considered a problem, its combination with any form of heparin therapy is. Intraoperative heparinization during cardiac or vascular surgery can be safely performed provided a minimum time interval between the regional anaesthetic block and the subsequent heparinization is respected and indwelling catheters are removed after the disappearance of any remaining heparin effect. Similarly, central neural blockade in combination with the thromboprophylactic use of standard unfractionated heparin or low-molecular-weight heparins is possible if: (1) only thromboprophylactic heparin doses are used; and (2) a specific minimum time interval between the previous or the next dose of the anticoagulant and the initiation of the block or the removal of the indwelling catheter is observed.     

Problems and pitfalls in blepharoplasty

Complications during or after blepharoplasty operations are described. These range from errors in assessing the patient's psychological state and the state of their health, through the more common physical sequelae of bleeding with haematoma formation, ectropion, hypertrophy of scars, etc., to complications affecting the function of the eye itself. The possibility of blindness arising as a result of blepharoplasty surgery is discussed, as are the theories of its causation, and the steps which may be taken to avert permanent loss of vision.     

Spinal haematoma following epidural analgesia

A patient who developed an epidural haematoma with multifactorial aetiology (bleeding diathesis, ankylosing spondylitis, chronic alcoholism and acute pancreatitis) after epidural analgesia for pain relief is described. Our conclusion is that adequate laboratory screening of blood coagulation, including platelet count, should be carried out in this category of patient before attempted epidural blockade, the risks of which must be weighed against the benefits. The block should be allowed to wear off intermittently and repeated neurological assessment performed if an epidural catheter is used for repeated injections or for a continuous infusion of local anaesthetic. Neuroradiological examination should be carried out promptly if an epidural haematoma is suspected and surgical decompression performed without delay if the diagnosis is confirmed.     

Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature

CONTEXT: Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas. FINDINGS: A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively. Written consent for publication was obtained from the patient. Clinical Relevance: The junctional location of the first lumbar vertebra, and the structural weakness from normal bone being replaced by the haemangioma, probably caused it to fracture under axial loading. This pathological fracture caused bleeding from the vascularized bone, resulting in cord compression.     

Haematoma block for fractures of the wrist: a cause of compartment syndrome

A case of compartment syndrome after haematoma block for a fracture of the distal radius is reported. This seems to be the first report of this complication. A review of the literature revealed seven other cases of compartmental ischaemia reported after fracture of the distal radius, and a haematoma block was used in all the cases where the type of anaesthesia was known. It is suggested that the additional fluid added for a haematoma block can precipitate a compartment syndrome, which may be more common than the scarcity of cases reported would indicate.     

Electrocoagulation in the surgery of inguinal hernias

One hundred and sixty patients with inguinal hernias were operated with pure tissue repair method (35 of them with radioscalpel) and 38 patients -- with no-tension plastic operation on the inguinal canal (19 of them with radioscalpel). There were no cases of bleeding, haematoma, seroma and wound infection when radioscalpel Surgitron was used. Herniotomy with Surgitron provides good short- and long-term results.     

Verbesserte Interpretation der intraoperativen Myelographie bei dorsaler Wirbelsäuleninstrumentierung

Intraoperative assessment of the spinal canal during dorsal instrumentation for vertebral fractures which narrow the canal is facilitated by myelography. However, the flow of contrast medium around a displaced fragment may result in an erroneous interpretation of canal patency. By performing myelography prior to instrumentation and reduction of the fracture, a chance in myelography-findings after reduction can clearly be caused only by successfull repositutioning of the displaced fragment. The possibility of an incorrect interpretation of the investigation can thus be reduced.     

Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy

The actual incidence of neurological dysfunction resulting from haemorrhagic complications associated with neuraxial block is unknown. Although the incidence cited in the literature is estimated to be <1 in 150,000 epidural and <1 in 220,000 spinal anaesthetics, recent surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increases with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard unfractionated heparin or low molecular weight heparin). The decision to perform spinal or epidural anaesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy is made on an individual basis, weighing the small, although definite risk of spinal haematoma with the benefits of regional anaesthesia for a specific patient. Coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation must be carefully monitored during the period of neuraxial catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal haematoma. Vigilance in monitoring is critical to allow early evaluation of neurological dysfunction and prompt intervention. An understanding of the complexity of this issue is essential to patient management.     

预防腰椎管术后硬膜外纤维瘢痕粘连的实验研究与临床观察

目的观察腰椎板切开椎板关闭成形术后椎板愈合、椎管内纤维瘢痕增生和硬膜外粘连情况。方法采用山羊14只制作动物模型,切开两个节段腰椎椎板,分别采用原位椎板关闭和椎板部分后移关闭两种手术方式,观察术后2、4、6、8、12、16、24周,椎板愈合和椎管内粘连情况。临床上采用腰椎板切开椎板原位关闭成形术处理椎管内病变患者46例,通过X线和CT检查观察椎板愈合和椎管内粘连情况。结果术后12周与16周,关闭的椎板均骨性连接;24周,关闭的椎板完全骨性愈合。后移椎板连接处较原位关闭椎板明显增厚;椎管内壁连接处轻微隆起。椎管内少量瘢痕增生粘连,可锐性分离。临床病例术后半年X线提示椎板截骨线消失。CT提示椎板截骨线骨质愈合,未见椎板连接处大量骨痂生成,椎管完整,硬膜囊无变形移位,硬膜同椎板间隙清楚。结论椎板原位关闭较椎板部分后移关闭骨质愈合速度快、愈合质量高。腰椎板切开椎板关闭成形术能有效地防止椎管内纤维瘢痕增生和硬膜外粘连的形成。     

BLEEDING TIME: IS IT A USEFUL CLINICAL TOOL?

The bleeding times of five volunteers were assessed individuallyby each of 12 observers. The reliability of the measurementsobtained was examined by comparing statistically the variabilitybetween subjects and between observers. This variability wasfound to be similar for both groups. Consequently, we suggestthat the bleeding time estimation is an unreliable test andshould not be used in isolation without reference to the salientfeatures of a history and examination, when determining if anindividual patient is at risk of haematoma formation as a complicationof regional anaesthetic techniques.     

The risk of vertebral canal complications in 2837 cardiac surgery patients with thoracic epidurals

BACKGROUND: Recent communications in the medical press have suggested that the rate of vertebral canal complications following epidural catheter placement is increasing in frequency, in particular the incidence of epidural abscess (Hearn M. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2003; 90 (5): 706-7; Govasi C, Bland D, Poddar R, Horst C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2004; 92 (2): 294-5). We wished to investigate this in our population of cardiac surgical patients. METHODS: We performed a retrospective review of the data from all patients who had undergone coronary artery bypass grafting or valve replacement surgery in our hospital over the past 8 years. This involved a review of computer databases, logbooks, radiology records, admission records, intensive care transfers, pain team ward round data and follow-up outpatient data referrals. RESULTS: In total, 2837 patient admissions were examined and reviewed by the authors. No episodes of vertebral canal haematoma or abscess were observed. CONCLUSIONS: Retrospective analysis of our working practice indicates that thoracic epidural anaesthesia and analgesia are safe in patients receiving cardiac surgery. We found no epidural haematoma or abscess in 2837 patients.     

保留腰椎板骨梁椎管扩大术治疗腰椎管狭症

目的 探讨不影响腰椎后柱结构和预防中椎管减压术后硬膜及神经根粘连的术式，方法 对4具人体腰椎20个腰椎椎板上下厚度、棘突上下沿的测量．和36例保留腰椎板骨梁、骶棘肌悬吊椎管扩大术病人的观察。结果 见各腰椎板下沿厚于上沿、棘突上沿长于下沿。结论 保留腰椎板骨梁的椎管扩大和骶棘肌悬吊术，有利于椎体后柱稳定和预防软组织与硬膜粘连的作用。     

Interhemispheric subdural haematoma complicated by intracerebral haematoma: Case report

Summary The authors describe a case of interhemispheric subdural haematoma which was followed by an ipsilateral intracerebral haematoma after an interval of about a half day. The intracerebral haematoma is considered to be the consequence of a haematoma induced thrombosis of cortical veins in connection with a bleeding diathesis due to previous anticoagulant therapy.     

Modified transpedicular approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures.

BACKGROUND CONTEXT: Conventional transpedicular decompression of the neural canal requires a considerable amount of lamina, facet joint and pedicle resection. The authors assumed that it would be possible to remove the retropulsed bone fragment by carving the pedicle with a high-speed drill without destroying the vertebral elements contributing to spinal stabilization. In this way, surgical treatment of unstable burst fractures can be performed less invasively. PURPOSE: The purpose of this study is to demonstrate both the possibility of neural canal decompression through a transpedicular approach without removing the posterior vertebral elements, which contribute to spinal stabilization, and the adequacy of posterior stabilization of severe vertebral deformities after burst fractures. STUDY DESIGN: Twenty-eight consecutive patients with complete or incomplete neurological deficits as a result of the thoracolumbar burst fractures were included in this study. All patients had severe spinal canal compromise (mean, 59.53%+/-14.92) and loss of vertebral body height (mean, 45.14%+/-7.19). Each patient was investigated for neural canal compromise, degree of kyphosis at fracture level and fusion after operation by computed tomography and direct roentgenograms taken preoperatively, early postoperatively and late postoperatively. The neurological condition of the patients was recorded in the early and late postoperative period according to Benzel-Larson grading systems. The outcome of the study was evaluated with regard to the adequate neural canal decompression, fusion and reoperation percents and neurological improvement. METHODS: Modified transpedicular approach includes drilling the pedicle for removal of retropulsed bone fragment under surgical microscope without damaging the anatomic continuity of posterior column. Stabilization with pedicle screw fixation and posterior fusion with otogenous bone chips were done after this decompression procedure at all 28 patients included in this study. RESULTS: Twenty-three of 28 patients showed neurological improvement. The percent of ambulatory patients was 71.4% 6 months after the operation. The major complications included pseudarthrosis in five patients (17.8%), epidural hematoma in one (3.5%) and inadequate decompression in one (3.5%). These patients were reoperated on by means of an anterior approach. Of the five pseudarthrosis cases, two were the result of infection. CONCLUSION: Although anterior vertebrectomy and fusion is generally recommended for burst fractures causing canal compromise, in these patients adequate neural canal decompression can also be achieved by a modified transpedicular approach less invasively.     

Haemostasis-altering drugs and central neuraxial block

PURPOSE: The purpose of this article is to review the literature concerning the use of epidural and spinal anaesthesia in patient receiving haemostasis-altering drugs, and to provide clear guidelines concerning the safe use of those anaesthetic in this category of patients. SOURCE: Relevant articles identified via a medline search and recommendation issued from consensus conferences were consulted. PRINCIPLE FINDINGS: Bleeding in the spinal canal is a very rare occurrence which makes it difficult to conduct randomised studies. Analysis of published case reports provide insight concerning the associated risk factors that may increase the risk of spinal haematoma. Those risk factors are predominantly, anticoagulation and puncture difficulties. Although many studies are reassuring, zero events does not mean that the risk is zero. Caution is always advised because the consequences of a spinal haematoma are devastating. CONCLUSION: Central neuraxial block should be avoided in fully anticoagulated patients. In partially anticoagulated patient, strict delays should be respected according to the pharmacology of the anticoagulants used, before institution of the central neuraxial block. Manipulation of epidural catheters should not be done unless the level of anticoagulation is low.