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Central neuraxial blocks and anticoagulation

Tyagi, A.; Bhattacharya, A.

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European Journal of Anaesthesiology (EJA): March 2003 - Volume 20 - Issue 3 - p 255
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A reply


We are grateful for the opportunity to respond to Dr Fattorutto's comments on our review [1]. His observations, however, are entirely misplaced and wrongly quoted. We will comment on his first observation about the data sources used for the two review articles on the subject of 'central neuraxial blockade in patients receiving anticoagulation' [2,3]. Wulf [2] not only sampled case reports from 1966 to 1995 using a MEDLINE search, but also cross-checked former case reports on the subject by continuous reading, over 10 yr, of the relevant anaesthesia journals. Similarly, Vandermeulen and colleagues [3] conducted a MEDLINE search and acquired further data by assessing previously published major reviews and large case series. Between 1906 and 1994, they identified 61 cases of spinal haematoma involving central neuraxial block. A similar overlapping approach for data collection was used by us to make the review [1] as detailed and complete as possible. A MEDLINE search for new cases (1995-2000), previous reviews with their cross-references [2-4] and other case reports gathered from relevant journals were included for the literature review.

Fattorutto refers to two earlier papers [2,3] that identify only one case of spinal haematoma with acetylsalicylic acid therapy and central neuraxial blockade. As correctly pointed out by us in our review [1], four of the 61 patients who developed spinal haematomas reported by Vandermeulen and colleagues were receiving antiplatelet therapy. While two of the patients had received aspirin (one along with concomitant systemic heparin therapy), one each had received ticlopidine and indomethacin. All three drugs incriminated are antiplatelet agents, and hence all four cases were included under the heading of 'spinal haematoma occurring in patients on antiplatelet therapy receiving central neuraxial blockade'. Wulf also reported three cases of spinal haematoma in patients with combinations of aspirin or other non-steroidal anti-inflammatory drugs and epidural anaesthesia. Probably Fattorutto has failed to appreciate that we reviewed all antiplatelet agents in relation to their effect on the incidence of spinal haematoma in patients receiving central neuraxial block, and not just 'aspirin and central neuraxial block'.

Our review reported that a single case of spinal haematoma in patients undergoing central neuraxial block with concomitant aspirin therapy [5] could be found by a MEDLINE search for 1995-2000. The last contention cited by Fattorutto that the MEDLINE search he conducted for 1966-2002 revealed only two cases [5,6] of this combination is a mere repetition of our observation. The second case referenced and detailed by him [6] was reported by Greensite and Katz in 1980 and thus obviously did not figure in our MEDLINE search conducted for 1995-2000. However, even this case report has been correctly referenced by us in the appropriate section of the text.

Thus, we do not agree to having used an inappropriate MEDLINE search or in having cross-checked incorrectly with former reviews on the subject. Rather, a detailed and more in-depth reading of the review is recommended before such observations are made.

A. Tyagi

A. Bhattacharya

Siddhartha Enclave; New Delhi, India


1. Tyagi A, Bhattacharya A. Central neuraxial blocks and anticoagulation: a review of current trends. Eur J Anaesthesiol 2002; 19: 317-329.
2. Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth 1996; 43: 1260-1271.
3. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165-1177.
4. Urmey WF, Rowlingson J. Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth Pain Med 1998; 23 (Suppl 2): 146-151.
5. Pryle BJ, Carter JA, Cadoux-Hudson T. Delayed paraplegia following spinal anaesthesia. Spinal subdural haematoma following dural puncture with a 25 G pencil point needle at T12-L1 in a patient taking aspirin. Anaesthesia 1996; 51: 263-265.
6. Greensite FS, Katz J. Spinal subdural hematoma associated with attempted epidural anesthesia and subsequent continuous spinal anesthesia. Anesth Analg 1980; 59: 72-73.
© 2003 European Society of Anaesthesiology