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Mount Sinai Medical Center, New York, New York
Address correspondence and reprint requests to Hatim A. Hyderally, MD, Mount Sinai Medical Center, 1 Gustave Levy Place, New York, New York 10029. Address e-mail to hhyderally{at}nj.rr.com.
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| Introduction |
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| Case Report |
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A single pass nontraumatic combined spinal-epidural was performed easily at the L3-4 interspace with a 18-gauge Tuohy epidural needle and 25-gauge Sprotte spinal needle. No paresthesiae were elicited and neither blood nor cerebrospinal fluid (CSF) was obtained through the epidural needle. Clear CSF was obtained through the spinal needle and 3 mL of 0.5% bupivacaine was injected intrathecally. An epidural catheter was passed easily at the first attempt and was secured at the skin with 5 cm within the epidural space. Blood was not aspirated through the catheter. A sensory level of T8 was obtained. Vital signs remained stable throughout the procedure, which was completed within 3 h. Hemostasis was adequate. Blood loss was estimated at 500 mL and the patient received 2500 mL of IV crystalloid. At the end of the procedure he complained of moderate pain at the surgical site and on examination he had recovered sensation and motor power in the lower limbs. An epidural infusion of fentanyl at a basal rate of 30 µg/h with 10 µg bolus dose every 20 min was initiated. Aspirin 325 mg was administered after the patient had returned to the floor at 5 pm and bid the next day for thromboprophylaxis. No other anticoagulants were given.
On the first postoperative day, the patient had normal sensation and strength in the lower extremities. On the second postoperative day at 6 am, he had complete sensory and motor loss in the lower limbs. At this time he was not examined neurologically by the orthopedic surgeons who assumed that the deficits were a result of the epidural. He was subsequently seen by an anesthesiology attending from the pain management service approximately 4 h later. At this time he stated that he had severe upper back pain radiating to both buttocks at midnight and was given 2 tablets of Percocet to relieve the back pain. A magnetic resonance imaging scan was performed at 11 am showing an epidural hematoma extending from T10 to T5. The epidural catheter was located at the junction of L2-3. The catheter was removed at this time and found to be patent and free of blood. An emergent surgical exploration was performed to evacuate the epidural hematoma of approximately 100 mL of blood compressing the cord at the thoracic level from T5 to T10. No blood was noted in the lumbar epidural space. The sensory deficit resolved slowly over the next 4 wk. He remained incontinent of urine and feces for an additional 4 wk. Motor power in the lower limbs returned over the next 2 mo, and he was able to walk with the aid of crutches.
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0.05), after spinal anesthesia and one case of paraplegia after epidural anesthesia in 30,413 cases, an incidence of 0.3/10,000. Wulf (3) also reviewed spinal/epidural hematoma after epidural anesthesia and reported the incidence to be as small as 1/190,000. Of the 51 spinal hematomas he identified, 5 were in patients with ankylosing spondylitis, and he suggested that the increased incidence may have been a result of traumatic bloody epidural taps arising from anatomical abnormalities. An exact analysis of the specific risk factor was not possible because the frequency of spinal-epidural anesthesia in these patients is not known. Most spinal/epidural hematomas occur spontaneously and are idiopathic. Kreppel et al. (4) reviewed 613 cases and reported that a third were idiopathic and that the others had a multifactorial etiology associated with trauma, arteriovenous malformations, and anticoagulant therapy, particularly low molecular weight heparin therapy. Practice guidelines (5,6) and previous series (7,8) suggest that aspirin and other nonsteroidal antiinflammatory drugs do not represent a significant risk for spinal bleeding.
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