Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Spinal Hematoma


Case Synopsis

A 69-year-old man underwent open abdominal aortic aneurysm repair under general anesthesia. An epidural catheter was inserted before induction for postoperative pain control. The anesthesiologist successfully placed the epidural catheter after the third attempt. Aspiration after insertion of the catheter yielded a blood-tinged column that cleared when the catheter was pulled out by 2 cm.

Despite using a relatively diluted mixture of local anesthetics (bupivacaine 0.125% and fentanyl 1 μg/mL), the patient experienced complete unilateral motor block in the first 2 hours after surgery that persisted despite the discontinuation of the epidural infusion. A magnetic resonance image revealed an epidural hematoma at T10. Immediate surgical decompression resulted in complete neurologic recovery.

Problem Analysis

Definition

In 1850 Tellegen was the first to describe the clinical symptoms of spinal cord hematoma (SCH). Anatomically, hematomas can occur in the epidural, subdural, or intramedullary areas of the spinal cord. Due to rarity of neurologic complications associated with central neuraxial blockades (CNBs), it is difficult to reach an accurate estimate of SCHs associated with them. Different authors based their findings on varying numbers/cohorts of patients, but the National Audit Project 3 (NAP3), which was conducted by the Royal College of Anesthetists and other organizations, identified 8 cases of SCH in 700,000 CNBs. The incidence of SCH was higher with epidural and combined spinal epidural anesthesia (17, 18 of 100,000) than with spinal or caudal anesthesia (2 of 100,000). Permanent neurologic deficit occurred in 5 cases of the 707,425 cases included in the audit. SCHs were rare when CNBs were used for labor, pediatric analgesia, or chronic pain management. The incidence increased substantially in patients over 70. Whether this increase is due to the associated comorbidities or the technique remains unknown.

Approximately 50% of SCHs are associated with catheter removal, and as many as 13% of cases are seen in patients without any preoperative risk factors. SCHs have widely varied etiologies ( Box 179.1 ) and occasionally occur spontaneously.

BOX 179.1
Causes of Spinal Cord Hematoma

  • Vascular malformations

  • Coagulopathies (congenital or acquired)

  • Myelitis/vasculitis

  • Syringomyelia

  • Mechanical trauma

  • Lumbar/epidural puncture

  • Neoplastic

  • Postsurgical

  • Idiopathic

Recognition

Classically, SCHs are known to present as localized back pain of varying intensity and nerve compression symptoms (motor, sensory, and autonomic). Significant percentage occurs after CNBs catheter removal. Back pain was less dominant a clinical feature when compared with motor weakness. Unilateral symptoms should be a red flag for spinal hematoma. Incomplete resolution of sensory or motor block after discontinuation of CNB infusion or after a single bolus should always be followed up and investigated.

Risk Assessment

Factors contributing to the occurrence of SCH can be divided into patient-related, technique-related, and drug-related factors.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts