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Anesthesiology:
doi: 10.1097/ALN.0b013e31824998e6
Education: Images in Anesthesiology

Images in Anesthesiology: Spinal Subdural Hematoma after Labor Epidural Placement

Barbara, David W. M.D.*; Smith, Benjamin C. M.D.; Arendt, Katherine W. M.D.
Section Editor(s): Hemmings, Hugh C. Jr. M.D., Ph.D.; Editor

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A LABOR epidural for a healthy 35-yr-old woman was complicated by dural puncture with an 18-gauge Weiss needle. An intrathecal catheter would not pass. An epidural catheter was placed one vertebral interspace higher. The patient had excellent labor analgesia but experienced lumbar back, left buttock, and generalized proximal left lower extremity pain aggravated by neck or back flexion, peaking in intensity 5 h after the epidural wore off. Serial physical examinations revealed no motor, sensory, bowel, or bladder deficits. Magnetic resonance imaging demonstrated scattered subdural fast spin echo T1 (fig. A) and T2 (figs. B and C) hypointensities with associated blooming artifact on gradient imaging (fig. D) most prominent at the L3 interspace (arrows) consistent with an acute spinal subdural hematoma. The pain completely resolved over 48 h without surgical intervention.
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Spinal subdural hematoma is a rare and potentially devastating complication of neuraxial anesthesia.1 Although more likely to occur in patients with coagulopathy from medications or various disease processes, spinal subdural hematoma may present without predisposing conditions.1,2 Symptoms include back pain, paraplegia, bowel and bladder dysfunction, and radicular pain.3 If neurologic deficit is present, prompt recognition of subdural hematoma is essential, with magnetic resonance imaging confirming the diagnosis. Treatment includes emergent surgery, with conservative management reserved for patients with mild, nonprogressing symptoms.2,3 Other causes of pain or neurologic deficit after neuraxial anesthesia include epidural abscess, epidural hematoma, meningitis, arachnoiditis, large volume injection with preexisting spinal stenosis, direct nerve trauma, or labor-associated nerve injury. Thorough review of the entire peripartum course, as well as careful history and neurologic examination, direct the anesthesiologist in obtaining imaging to differentiate hematoma from other etiologies.
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References

1. Edelson RN, Chernik NL, Posner JB: Spinal subdural hematomas complicating lumbar puncture. Arch Neurol 1974; 31:134–7

2. Singh DK, Chauhan M, Gupta V, Chopra S, Bagaria HR: Spinal subdural hematoma: A rare complication of spinal anesthesia: a case report. Turk Neurosurg 2008; 18:324–6

3. Subbiah M, Avadhani A, Shetty AP, Rajasekaran S: Acute spontaneous cervical epidural hematoma with neurological deficit after low-molecular-weight heparin therapy: Role of conservative management. Spine J 2010; 10:e11–5

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