Incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia

OBJECTIVE: To study the incidence in Catalonia of spinal cord compression due to spinal hematoma secondary to neuraxial anesthesia. METHODS: The incidence of hematoma was based on published cases (MEDLINE, the Spanish Medical Index [Indice Medico Espa?ol], and Google) or cases reported at medical meetings or conferences by anesthesiologists from Catalan hospitals from 1996 to 2005, inclusive. The annual number of neuraxial anesthesias (spinal, epidural, and combined) was estimated based on the ANESCAT 2003 survey and the total number of anesthesias was calculated using the ANESCAT 2003 survey in conjunction with the surgical reports of Catalan hospitals. RESULTS: A total of 11 cases of spinal hematoma after neuraxial anesthesia (7 after spinal anesthesia and 4 after epidural anesthesia) were reported or published from 1996 to 2005, inclusive. A total of 194 154 neuraxial anesthesias were performed in 2003 (126 560 spinal anesthesias and 5926 combined spinal-epidural anesthesias) and it was estimated that somewhat over 1 700 000 neuraxial anesthesias were performed over the 10 years reviewed. The incidence (95% confidence interval [CI]) of hematoma was 0.6 (95% CI, 0.3-1.2) per 100 000 neuraxial anesthesias, 0.6 (95% CI, 0.3-1.3) per 100 000 spinal anesthesias, and 0.7 (95% CI, 0.2-1.9) per 100 000 epidural anesthesias. CONCLUSIONS: The incidence of spinal hematoma after neuraxial anesthesia is slightly more than 1 per 150 000 anesthesias-a similar finding to that of other epidemiological studies. The incidence is slightly higher in epidural anesthesia. These data imply a risk of approximately 1 spinal hematoma per year in Catalonia.     

Spontaneous resolution of a paraparesis due to a dorsolumbar epidural haematoma associated with subarachnoid anaesthesia and postoperative analgesia using an epidural catheter

Spinal epidural haematoma after neuroaxial anaesthesia is a rare but serious complication. Most cases are attributed to anticoagulant therapy or bleeding tendency. It presents as an acute spinal cord compression and usually requires emergency surgical decompression. The interval between the onset of clinical signs and surgical evacuation is very important, influencing the neurological prognosis. We report a case of a spinal epidural haematoma after epidural analgesia in a patient who was treated with low molecular weight heparin for thrombo-prophylaxis in the perioperative period. In some cases, such as the one reported here, good neurological recovery can be achieved with conservative management.     

Technical difficulties in epidural blocks and spinal bleeding complications

The clinical cases of two patients with neurological complications following neuroaxial blocks are reported. The events took place in different institutions where thousands of central blocks were yearly performed. In both instances the blocking procedures presented technical difficulties needing repeated lumbar punctures. The first case concerns a patient receiving anticoagulant and fibrinolytic therapy for vascular pathology. This 89 year-old female experienced severe cord compression requiring surgical decompression and laminectomy. The second case regards a patient with previous minor surgical procedure requiring postoperative antiinflammatory treatment. This 74 year-old male experienced subarachnoid hemorrhage and spinal/epidural hematoma as shown by NMR. The symptoms regressed with steroid therapy. The authors emphasise the risks of mechanical trauma of epidural or spinal anesthesia both during positioning or removal of an epidural catheter. The problem related to the compatibility between central blocks and antithrombotic/anticoagulant prophylaxis/therapy is now of primary concern and has led to publications about guide lines on this topic. If central block is carried out in patients with bleeding diathesis it is mandatory to co-ordinate multidisciplinary assistance for early detection of significant symptoms of the above described complications and subsequent treatment.     

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.     

Chronic spontaneous spinal epidural hematoma – a rare cause of cervical myelopathy

Spontaneous spinal epidural hematoma (SSEH) is a rare entity. SSEH occurring anterior to the spinal cord in the cervical region with spontaneous improvement is even more rare. One such rare case is reported. A 19-year-old male presented with a 2-month history of neck pain and weakness of the upper and lower limbs without sensory deficit. Magnetic resonance imaging (MRI) showed features of anteriorly located cervical epidural hematoma. As the patient had started improving by the time he sought neurosurgical consultation, he was treated conservatively, and he improved over a period of 2 months. This case illustrates that, though rare, chronic spontaneous spinal epidural hematoma should be entertained in the differential diagnosis of cervical cord compression. Spontaneous resolution of spinal epidural hematomas is known to occur, and in properly selected cases, surgical intervention may not always be necessary.     

Survey of nerve injury associated with epidural/spinal anesthesia in Japan which occurred in the year 2004

BACKGROUND: The incidence of nerve injury associated with epidural/spinal anesthesia has not been sufficiently investigated in Japan. PURPOSE: The incidence of nerve injury caused by inappropriate epidural/spinal puncture or catheter placement was examined using data obtained by a survey conducted by the Japanese Society of Anesthesiologists for the year 2004. METHODS: In a survey for the year 2004, 1,218,371 anesthetic procedures were registered, among which 548,819 patients were estimated to be anesthetized under epidural/spinal procedures with or without general anesthesia. Twenty nine patients were reported to have incurred nerve injury due to inappropriate epidural/spinal puncture or catheter placement. RESULTS: Seven cases of spinal cord and 22 cases of peripheral nerve injury were reported, with estimated incidences of 1/78,000 and 1/25,000 procedures, respectively. Spinal cord injury developed before the start of surgery in 4 cases, intraoperatively in 1 case, and after the end of surgery in 2 cases. Permanent nerve damage developed in 4 patients with spinal cord injury and 7 patients with peripheral nerve injury. Eighty three percent of these events were reported to be preventable. CONCLUSIONS: The incidence of nerve injury caused by regional anesthesia in Japan seems to be comparable to those reported in the developed countries. To reduce the incidence of this complication, cautious evaluation of the risk/benefit balance in performing regional anesthesia, improving education and supervision of the procedures, and establishing better communication between anesthesiologists and surgeons concerning the timing of catheter removal and the postoperative coagulation state seem to be important.     

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.     

Spontaneous extradural hematoma localized in the ventral side of the thoracic spinal cord--a case report

A case of spontaneous spinal extradural hematoma was reported. The patient, a 25-year-old housewife, was hospitalized with back pain, followed by paralysis of both legs and urinary disturbance during next 2 hours. A myelogram demonstrated that contrast medium was incompletely blocked at the level from the 3rd to the 4th thoracic spine by extradural mass. Unfortunately X-ray CT scan was not examined, however, a NMR-CT scan excluded disc protrusion and dissecting aneurysm of the aorta. Eight hours after onset, wide laminectomy was performed as emergency operation and an epidural hematoma located in the ventral side with compression of the thoracic cord was removed as completely as possible. She was discharged with excellent recovery after operation. The spontaneous spinal epidural hematoma is rare emergency. The exact etiology is unknown, and no explanation is offered as to why the hematoma is usually dorsal in location. To our knowledge, only three cases of spinal epidural hematoma which located in the ventral side were reported. Considering from our experience and other reports, it seems to be the most important point to avoid the unnecessary pressure on the spinal cord and to search the exact bleeding point in the operative procedure of ventral epidural hematomas.     

Hématome péridural chez une parturiente au décours ďun choc hémorragique

PURPOSE: Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES: A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION: In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.     

Subdurales Hämatom nach Duraperforation

Subdural hematoma may occur as rare, although intervention- specific complications of accidental dural puncture by neuroaxial block. Bleeding may be caused by rapid cerebrospinal fluid loss related to traction on fragile intracranial bridging veins. This article reports a case of postdural puncture headache in a 43-year-old woman after accidental dural puncture during attempted placement of an epidural catheter for induction of abortion. Bed rest, analgesics, theophylline and hydration were to no avail and only a blood patch improved the headaches. The patient presented 7 weeks later with headache and left-sided hemiplegia. Magnetic resonance imaging showed a right frontoparietal subdural intracranial hematoma which had to be surgically evacuated. The patient recovered completely. Intracranial hematoma is a rare but serious complication of central neuroaxial block. According to current German jurisdiction this risk must be addressed when informed consent is obtained. Intracranial hematoma should be considered in the differential diagnosis of atypical headache and neurological signs (e.g. focal motor and sensory deficits and seizures) following neuroaxial block and adequate image diagnostics should be carried out without delay.     

Enoxaparin associated with hugh abdominal wall hematomas: a report of two cases

Enoxaparin is a low-molecular-weight heparin used for prophylaxis against deep venous thrombosis. Indications include hip and knee replacement surgery, risk of deep venous thrombosis during abdominal surgery, and prevention of ischemic complications of unstable angina and non-Q-wave myocardial infarction. Its efficacy in the prevention of the above complications has been previously studied; however, the liberal use of enoxaparin is not without incident. Complications of enoxaparin include hemorrhage, thrombocytopenia, and local reactions. Since 1993 there have been more than 40 reports of epidural or spinal hematoma formation with the concurrent use of enoxaparin and spinal/epidural anesthesia or spinal puncture. Herein reported are two cases of abdominal wall hematomas in patients receiving prophylaxis with enoxaparin. Both patients sustained an unexplained fall in the hematocrit and abdominal pain. A CT scan confirmed the diagnosis. One patient recovered uneventfully; however, the other patient, on chronic hemodialysis, became hemodynamically unstable and hyperkalemic and sustained a fatal cardiac arrhythmia. An extensive review of the literature revealed no similar cases of abdominal wall hematomas associated with enoxaparin although other complications, including spinal and epidural hematomas, psoas hematomas, and skin necrosis have been reported. The extended use of enoxaparin as an anticoagulant requires the physician to be vigilant of these rare complications. Bleeding can occur at any site during therapy with enoxaparin. An unexplained fall in the hematocrit or blood pressure should lead to a search for a bleeding site.     

Acute spinal subdural hematoma. A case report and review of literature

A case of acute spinal subdural hematoma is reported in a 24-year-old woman. Presentation occurred in the postpartum period, 4 days following epidural anesthesia. Emergency decompressive laminectomy attained partial recovery. Subsequent pathology demonstrated evidence of a low-grade ependymoma. Reported cases of spinal subdural hematomas are reviewed and compared with the characteristics of this unique case.     

Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic ingestion: a case report

The authors report a case of spontaneous spinal epidural hematoma causing paraplegia secondary to a qualitative platelet disorder from excessive garlic ingestion. The case also demonstrates satisfactory recovery from thoracic spinal epidural hematoma in a nonagenarian. Recovery from severe spinal cord compression can occur even in the very elderly.     

Lumbar neuraxial procedures in thrombocytopenic patients across populations: A systematic review and meta-analysis

IntroductionThere is currently no consensus regarding the minimum threshold platelet count to ensure safe neuraxial procedures. Numerous reports describe the safe performance of lumbar punctures in severely thrombocytopenic patients but reports of neuraxial anesthetic procedures in thrombocytopenic patients are limited. To date, the focus on specific populations in contemporary reviews has failed to include any actual hematoma cases. This systematic review aggregates reported lumbar neuraxial procedures from diverse thrombocytopenic populations to best elucidate the risk of spinal epidural hematoma.MethodsMEDLINE, Embase, Cochrane, CINAHL databases were searched for articles about thrombocytopenic patients (<100,000 × 10⁶/L) who received a lumbar neuraxial procedure (lumbar puncture; spinal, epidural, or combined spinal-epidural analgesia/anesthesia; epidural catheter removal), whether spinal epidural hematoma occurred.ResultsOf 4167 articles reviewed, 131 met inclusion criteria. 7476 lumbar neuraxial procedures were performed without and 33 procedures with spinal epidural hematoma. Within the platelet count ranges of 1–25,000 × 10⁶/L, 26–50,000 × 10⁶/L, 51–75,000 × 10⁶/L, and 76–99,000 × 10⁶/L there were 14, 6, 9, and 4 spinal epidural hematomas, respectively. An infection point and narrow confidence intervals were observed near 75,000 × 10⁶/L or above, reflecting a low probability of spinal epidural hematoma in this sample. Of the 19 spinal epidural hematoma cases for which the onset of symptoms was reported, 18 (95%) were symptomatic within 48 h of the procedure.ConclusionsSpinal epidural hematoma in thrombocytopenic patients is rare. In this sample of patients, an inflection point and narrow confidence intervals are observed near a platelet count of 75,000 × 10⁶/L or above, reflecting an estimated low spinal epidural hematoma event rate with more certainty given a larger sample size and inclusion of spinal epidural hematoma cases. Thrombocytopenic patients should be monitored, particularly in the first 48 h, and educated about symptoms concerning for spinal epidural hematoma.     

自发性脊柱硬膜外血肿的非典型MRI表现与鉴别诊断

目的 提高对自发性脊柱硬膜外血肿非典型MRI表现的认识.方法 对2000年至2008年来院的10例自发性脊柱硬膜外血肿非典型MRI表现进行分析,男7例,女3例;年龄12--64岁,平均32.1岁.所有病例均无明显的外伤史.常规行矢状位T1WI、T2WI,横轴位TwI,8例行增强扫描.结果 血肿呈梭形、椭圆形,位于脊髓的侧后方或后方的硬膜外腔.血肿发生于颈段5例,胸段3例,胸腰段2例.病灶与脊髓之间有一低信号线状影相隔,尤以T2WI显示最佳.血肿范围多在2～4个椎体,总量约5～10 ml,均值为(6.9±1.8)ml.在T1WI图像上,6例表现为等信号,4例表现为高信号;在T2WI图像上,6例表现为混杂高信号,4例表现为混杂低信号.5例血肿壁边缘轻度强化.6例血肿MRI信号比较典型.4例血肿MRI信号不典型.活动性出血以及血肿因时间而演变是血肿征象不典型的原因.本组4例误诊的原因:(1)活动性出血所致血肿征象不典型;(2)血肿位于狭窄的腔隙内;(3)临床上无外伤史.结论 根据血肿演变的规律,结合起病时间及可能存在活动性出血对血肿MRI信号进行分析,有利于对非典型血肿的诊断和鉴别诊断.     

Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging. Case report

A traumatic epidural hematoma of the cervical spine is reported in a 13-year-old girl. The patient recovered spontaneously over several days without surgical intervention. The diagnosis was made on magnetic resonance (MR) imaging, which also demonstrated subsequent resolution of the hematoma. The etiological factors of spinal epidural hematomas are reviewed and the utility of MR imaging in differentiating other causes of acute spinal cord injury is emphasized.     

自发性椎管内硬膜外血肿的影像学及临床特征

目的分析自发性椎管内硬膜外血肿(SSEH)的影像学特征及临床治疗效果。方法回顾性分析2008年6月—2018年9月泰州市人民医院脊柱外科收治的SSEH患者临床资料,分析其影像学表现。采用硬膜外脊髓压迫(ESCC)分级评估硬膜外占位对硬膜囊及脊髓的压迫程度,美国脊髓损伤协会(ASIA)分级评估神经功能,疼痛视觉模拟量表(VAS)评分评估疼痛情况。结果本研究共纳入12例患者,年龄25 ～ 74岁,中位年龄64.5岁。MRI显示SSEH大多呈梭形、椭圆形,且多位于脊髓侧后方或后方的硬膜外腔。血肿最多发于颈段(4例)或颈胸段(4例)。血肿累及1 ～ 4个节段,平均2.6个节段。T1WI MRI上7例表现为等信号,4例表现为高信号,1例表现为低信号;T2WI MRI上10例表现为高/混杂信号,2例表现为低信号。血肿压迫脊髓程度(ESCC分级)与患者神经功能损伤程度(AISA分级)密切相关(r=0.85,P 0.01)。7例患者行手术治疗,其中5例术后神经功能有所恢复,2例术前ASIA分级为A级的患者末次随访时仍为A级;5例采用非手术治疗,治疗后神经功能均有所恢复,VAS评分下降。结论 MRI是诊断SSEH的最佳检查方法。根据患者神经功能损伤及进展情形,可选择非手术治疗或尽早手术治疗。     

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.     

Acute non-traumatic extensive subdural spinal hematoma

Acute spinal subdural hematoma is a somewhat rare pathology. Its severity comes from the constitution of an acute spinal cord compression. In many cases MRI is useful for the differential diagnosis with the epidural hematoma. A 79-year-old patient was referred for emergency neurosurgery for acute spinal cord compression. The vascular risk in this patient was significant: hypertension, oral anticoagulants. Clinically, acute non-traumatic subdural spinal hematoma was suspected. The spinal cord MRI was in favor of the diagnosis which was confirmed intraoperatively. The surgical procedure revealed an extensive hematoma which infiltrated the spinal cord. The diagnosis of nontraumatic subdural spinal hematoma may be difficult in some cases and correctly established only during the surgical procedure. In comparison with reports in the literature, we discuss the underlying mechanisms of this hematoma. Spinal subdural haematoma must be considered in patients taking anticoagulant therapy or with a coagulation disorder who present signs of acute spinal cord compression. MRI sagittal T1 and T2-weighted images are adequate and reliable for diagnosis of spinal subdural hematoma. Prompt surgical evacuation of this hematoma is crucial.