Spinal epidural hematoma is a well-known and potentially devastating complication after neuraxial anesthesia. The incidence of epidural hematoma was traditionally believed to be estimated at 1:15,000 for patients receiving epidural blockade. Epidemiologic surveys by Moen et al,1 however, have found the incidence to be as frequent as 1:3600 for women undergoing total knee arthroplasty compared with 1:200,000 for those receiving labor analgesia.1–3 Patients usually present with severe, localized, constant back pain with or without a radicular component that may mimic disk herniation. Associated symptoms may include weakness, numbness, and urinary or fecal incontinence. Variable presentations do occur, however, with some patients experiencing unilateral pain and isolated sensory or motor blocks.4–7 Morbidity and mortality related to epidural hematoma remain quite high, despite increased recognition, with mortality rates as frequent as 8% and absent or incomplete recovery despite treatment as much as 50%.8 The interval to surgical intervention and degree of preoperative deficit are the 2 most critical components determining improved or complete recovery.8–11
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An 86-year-old woman with a symptomatic type 3 hiatal hernia was admitted for an elective Collis-Nissen fundoplication. Her medical history included hypertension, hyperlipidemia, and gastroesophageal reflux disease. The patient also reported a history of osteoporosis with known osteoporotic compression fractures in the thoracic spine, which had been managed conservatively. Until 2 weeks earlier, she had been receiving aspirin 81 mg daily. Her routine preoperative lab work including prothrombin time, partial thromboplastin time, and a complete blood count with platelets were within normal limits. On the day of surgery, an epidural catheter was inserted at the T7-8 level using an 18-gauge 3.5” Tuohy needle. The procedure was uneventful with 1 needle pass required. No blood was noted during insertion of or on aspiration from the catheter. The patient did not report any paresthesias during the procedure. An infusion of 0.1% bupivacaine with 2 mcg/mL fentanyl was initiated at 5 mL/h before surgical incision and continued throughout the intraoperative and postoperative period. The patient underwent uneventful general endotracheal anesthesia; her trachea was extubated in the operating room, and the patient was transferred to the intensive care unit per routine protocol. The patient was seen later that night by the Acute Pain on-call resident for the evaluation of 8 of 10 surgical incision pain. Evaluation did not reveal a sensory level, and a bolus of 5 mL 2% mepivacaine provided adequate analgesia and a resulting T6-10 sensory level. Eighteen hours after epidural placement, subcutaneous (SQ) heparin 5000 units 3 times daily was begun at 9 AM on postoperative day 1. The patient had minor episodes of hypotension on postoperative day 1, and the bupivacaine concentration was decreased to 0.0625% at 5 mL/h. The patient also received 3 doses of ketorolac IV on postoperative day 1 at 1 AM, 2, and 8 PM for postoperative pain and reported excellent pain relief. On postoperative day 2 at 4 AM, 19 hours after the first dose of heparin and 27 hours after the first dose of ketorolac, the patient began to complain of right lower extremity weakness and on examination was found to have right lower extremity weakness, graded 2/5 primarily in the distribution of the right femoral nerve. Sensation was completely intact bilaterally. She was also noted to have a brisk right patellar reflex. The patient denied any midline back tenderness, radicular pain, or fecal/urinary incontinence. Neurology and neurosurgery were consulted, and q1 hour neurological checks were begun. Given the isolated right lower extremity weakness, lack of back tenderness, or sensory deficit in addition to the other comorbidities, a postoperative cerebrovascular accident was felt to be the leading diagnosis. Spinal cord infarction or epidural hematoma was considered less likely given the unilateral presentation as well as pure motor symptomatology. Brain magnetic resonance imaging (MRI) and magnetic resonance angiogram were unremarkable, but a thoracic MRI revealed a large epidural hematoma extending from the T2 through T12 level (Figs. 1 and 2). Also noted in the MRI were multiple remote compression fractures of the thoracic and lumbar spine. The patient was immediately taken to the operating room for emergent T5-10 laminectomy and evacuation of epidural hematoma. Immediately postoperatively, the patient had completely recovered neurological function in the right lower extremity and normal motor strength (Fig. 3). The patient did well and was eventually discharged on postoperative day 8 (Collis-Nissen), having made a full recovery. On routine follow-up, the patient has not had any functional limitations and is neurologically intact without deficit.
This case highlights a patient receiving SQ heparin dosed 3 times a day, starting 18 hours after uncomplicated placement of a T7-8 epidural. The safety of SQ heparin with 3 times a day dosing and neuraxial anesthesia has not been well established with randomized clinical trials. Davis et al.12 attempted to study the effect of using SQ heparin with 3 times a day dosing on 928 patients receiving neuraxial anesthesia. However, their results lacked power, and ultimately, they were left with the conclusion that a larger sample size was needed to show a relationship between 3 times a day dosing of unfractionated heparin (UFH) and epidural hematoma.12 The meta-analysis done by Phung et al.13 showed moderate-quality evidence, suggesting that SQ heparin twice daily and 3 times a day do not differ in effect on deep venous vein thrombosis, pulmonary embolism, major bleeding, and mortality. As outlined in the 2010 American Society of Regional Anesthesia (ASRA) guidelines for neuraxial anesthesia and anticoagulation, there is a lack of evidence to support a recommendation on the use of 3 times a day dosed SQ heparin. However, given a lack of any increased efficacy compared with that with q12 hour dosing, the current advisory is that “patients not to receive 3 times a day of SQ heparin while the epidural anesthesia is still maintained.”2
In addition to SQ heparin, this patient also received ketorolac starting 10 hours after epidural placement. Nonsteroidal anti-inflammatory drugs alone do not significantly increase the risk of epidural hematoma, and there are no recommendations requiring an alteration of its use about neuraxial anesthesia. However, combination therapy with UFH, low molecular weight heparin, oral anticoagulants, and thrombolytics has demonstrated an increase in the incidence of spontaneous hemorrhagic complications.2,14–17 Current ASRA guidelines recommend “against the performance of neuraxial techniques if the concurrent use of other medications affecting clotting mechanisms, such as oral anticoagulants, UFH, and low molecular weight heparin, is anticipated in the early postoperative period because of the increased risk of bleeding complications.2 Based on a lack of definitive evidence with randomized trials, the magnitude of increased risk is unclear.
While the usual presentation for patients with epidural hematoma is severe, localized back pain with or without radicular radiation in addition to bilateral sensory and motor loss along the affected distribution, the presentation can be quite variable, and thus, a high level of clinical suspicion is warranted for any unexpected symptoms compatible with spinal epidural hematoma. As this and other case reports demonstrate,4–7 patients may have completely unilateral symptoms and pure sensory or motor blockade even with massive epidural hematoma and severe pathology. Pure unilateral motor or sensory symptoms without associated back pain can often confuse the diagnosis with that of a cerebrovascular accident.18,19 This is obviously important as the treatment plans are considerably different, and anticoagulation in the setting of established epidural hematoma can be catastrophic. The most accurate diagnostic test remains spinal MRI and should be performed early to allow prompt diagnosis and treatment.20
The critical factors determining postoperative morbidity include the preoperative neurologic deficit and the interval between onset of symptoms and surgical evacuation of the hematoma. Several studies have shown that even with a large epidural hematoma involving multiple nerve roots, if the diagnosis is rapidly made, and the hematoma evacuated, full recovery can occur.8–11
The presentation of spinal epidural hematoma can be quite variable. Despite the lack of definitive data guiding therapy, based on the results of this case and the recommendations from ASRA, the practice at our institution has since changed. We recommend that while neuraxial anesthesia is in place, patients receive twice daily rather than 3 times a day heparin. If the decision is made that 3 times a day dosing is required, then patients do not receive any concurrent anticoagulation or antiplatelet medications such as ketorolac.
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