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REGIONAL ANESTHESIA

Epidural Hematoma Unrelated to Combined Spinal-Epidural Anesthesia in a Patient with Ankylosing Spondylitis Receiving Aspirin After Total Hip Replacement

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.

	Abstract

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Although rare, major complications after spinal and epidural anesthesia do occur. The safety of spinal and epidural anesthesia has been well established. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinal-epidural anesthetic. Most epidural hematomas are spontaneous and idiopathic.

	Introduction

Top Abstract Introduction Case Report Discussion Conclusion References

 
Major neurological deficits after spinal and epidural anesthesia are extremely rare. We report a case of postoperative epidural hematoma in a patient with ankylosing spondylitis (AS) after total hip replacement (THR) who received aspirin for thromboprophylaxis that was unrelated to the combined spinal/epidural anesthetic.

	Case Report

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A 55-yr-old male patient weighing 80 kg and 175 cms tall with moderate AS restricted to the sacroiliac joints and thoracolumbar spine with kyphosis presented for a revision THR. His medical history was significant for insulin-dependent diabetes. His current medications were neutral protamine Hagedorn (NPH) insulin, glipizide, lisinopril, and aspirin 81 mg daily, which was not discontinued before surgery. He was neurologically intact and did not have a history of bruising easily or gingival bleeding. The only previous surgery was a primary THR 17 yr earlier under uneventful epidural anesthesia performed by the author.

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.

	Discussion

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The safety of spinal and epidural anesthesia has been well established since the classical reports by Dripps and Vandam in 1954 (1). Auroy et al. (2), in a prospective review in France in 1997, demonstrated the extremely infrequent incidence of neurological complications, 6 ± 1 per 10,000 cases (P 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.

	Conclusion

Top Abstract Introduction Case Report Discussion Conclusion References

 
This patient developed the epidural hematoma approximately 36 h after the spinal/epidural procedure. He had ankylosing spondylitis and received aspirin perioperatively. The hematoma was located in the thoracic region away from the site of the spinal/epidural procedure. In addition, the tip of the epidural catheter was located in the lumbar spine. Previous authors have stressed the importance of repeated neurological examination in patients after neuraxial anesthesia who may be at increased risk for developing a spinal hematoma (7,8). Most importantly, a high degree of awareness is required to exclude a developing spinal hematoma in a patient who complains of new or worsening neurological symptoms after spinal and epidural anesthesia (9). However, the neurologic deficits may not be related to the regional anesthetic, as demonstrated by the current case. It is noteworthy that the surgeon attributed the deficits to the epidural infusion, even though it contained only fentanyl. The delay in the diagnosis and subsequent surgical intervention may have affected this patient's neurological recovery.

	References

Top Abstract Introduction Case Report Discussion Conclusion References

 

1. Dripps RD, Vandam LD. Long-term follow up of patients who received 10,098 spinal anesthetics: failure to discover major neurological sequelae. JAMA 1954;156:1486–91.
2. Auroy Y, Narchi P, Messaih A, et al. Serious complications related to regional anesthesia: results of a prospective survey in France. Anesthesiology 1997;87:479–86.[ISI][Medline]
3. Wulf H. Epidural anaesthesia and spinal hematoma. Can J Anaesth 1996;43:12;1260–71.
4. Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1–49.[Medline]
5. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth 2003;28:172–97.[ISI][Medline]
6. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165–77.[Free Full Text]
7. Horlocker TT, Wedel DJ, Schroeder DR, et al. Perioperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80:303–9.[Abstract]
8. Urmey WF, Rowlingson J. Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth 1998;23:146–51.
9. Gustafsson H, Rutberg H, Bengtsson M. Spinal hematoma following epidural analgesia. Anaesthesia 1988;43:220–2.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (4) Citing Articles via Google Scholar Google Scholar Articles by Hyderally, H. A. Search for Related Content PubMed PubMed Citation Articles by Hyderally, H. A. Related Collections Complications Regional Anesthesia

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999