Anesth Analg 2002;94:77-78
© 2002 International Anesthesia Research Society
AMBULATORY ANESTHESIA
Epidural Hematoma After Outpatient Epidural Anesthesia
Andre Gilbert, MD,
Brian D. Owens, MD, and
Michael F. Mulroy, MD
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington
Address correspondence to Brian D. Owens, MD, Department of Anesthesiology, B2-AN, 1100 9th Ave., PO Box 900, Seattle, WA 98111. Address e-mail to anebdo{at}vmmc.org
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Abstract
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Epidural hematoma is a rare event after spinal or epidural anesthesia in healthy patients without coagulopathy or traumatic needle insertion (1,2). We present a case of a healthy patient who experienced an acute lumbar epidural hematoma after epidural anesthesia for an outpatient knee arthroscopy.
IMPLICATIONS: Epidural hematoma is a rare complication of epidural anesthesia in healthy patients. Expedient diagnosis and treatment are essential to avoid permanent neurologic deficits. In an outpatient setting, patients should be instructed to communicate symptoms of severe back pain or weakness early.
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Case Report
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A 35-yr-old woman presented for left knee arthroscopy and screw removal. There was no history of unusual bleeding diathesis. She denied easy bruising. She had experienced epidural anesthesia for knee arthrotomy, her two vaginal deliveries were unremarkable, and she had used both ibuprofen and ketorolac without problems. She was uncertain of the anesthetic technique performed during labor. Her only medication was oral contraceptives.
In the induction area, the L3-4 epidural space was identified easily at 4.5 cm on the first attempt with an 18-gauge Tuohy needle and loss-of-resistance technique with saline. Aspiration and a test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine was negative for intravascular placement. Seventeen milliliters of 3% chloroprocaine with 1:200,000 epinephrine was dosed incrementally through the needle. A 20-gauge polyamide epidural catheter (Burron) was advanced 5.5 cm into the epidural space, producing a transient paresthesia in the right lower extremity. In the operating room, sensory block to temperature was observed to the T10 dermatome, and adequate motor block was present; however, blood was easily aspirated from the catheter, and its further use was abandoned.
Ketorolac 30 mg was given IV 45 min after placement of the epidural. The operation was uneventful, and the patient was comfortable upon arrival at the postanesthesia care unit. Inspection of the epidural catheter after removal revealed an intact tip with blood on it. The block resolved completely 2 h after initial injection, and the patient was pain free when discharged home 30 min later.
Patients are instructed to rest for the remainder of the day and to limit themselves to moderate activity. They are allowed to ambulate with crutches and are told to contact the Outpatient Surgical Center or the Department of Anesthesia with any problems or questions. Our patient was transported via wheelchair to a car driven by her husband. On the way home she experienced excruciating back pain; she called the postanesthesia care unit at the Outpatient Surgical Center and was advised to return immediately. The pain varied, at times involving her right lower extremity. She received multiple doses of IV fentanyl and an additional dose of ketorolac, with minimal relief. In the next 2 h, she complained of right lower extremity weakness and tingling; the affected leg "gave out" when she stood up to use the restroom. She urinated successfully. At this time, neurological examination did not demonstrate a reproducible abnormality; it was difficult to assess whether the patient was truly weak or reluctant to give a full motor effort, because of pain. We believed that the most likely diagnosis was pain related to 3-chloroprocaine. Because the patient’s response to IV fentanyl was inadequate, we chose to administer a single dose of epidural fentanyl 50 µg. Her pain improved dramatically, but lateralizing neurological signs soon became apparent. All muscle groups of the right lower extremity were weak, especially hip flexion and ankle dorsiflexion. Sensation to light touch was normal. The right patellar tendon reflex was absent. At this time, the dressing around the operative site on the left knee was noted to be soaked with blood.
An emergency magnetic resonance imaging of the lumbar spine was performed, and it identified a posterior epidural hematoma occupying 80% of the spinal canal area from mid L1 to inferior L3 vertebral levels (Fig. 1). A neurosurgery consult was obtained, and emergent decompressive L1 to L3 laminectomy with hematoma evacuation was performed approximately 9 h after presentation. A coagulation profile obtained in preparation for surgery was normal: prothrombin time was 12.5 s with an international normalized ratio of 1.1, partial thromboplastin time was 28.2 s, platelet count was 219,000, and bleeding time was 8 min.
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Figure 1. A magnetic resonance image of the lumbar spine demonstrating an epidural hematoma at levels L1 to L3 (arrow).
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Postoperatively, the patient had weakness of her right hip adductors and had one episode of urinary retention on Postoperative Day 2. She was discharged from the hospital on Postoperative Day 4. Complete motor function returned over the next few weeks, and the only persistent deficit was a small area of dysesthesia on the lower lateral aspect of her right calf.
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Discussion
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Precise data on the incidence of epidural hematomas are lacking. In a review of the world literature from 1906 to 1994, Vandermeulen et al. (1) reported 61 patients experiencing this complication after epidural or subarachnoid block. Although 87% of these patients had a coexisting coagulopathy or traumatic needle insertion, or both, 13% of patients had no risk factors. Wulf (2) presented 16 additional cases in 1996. Of 1.3 million epidurals reviewed, 7 hematomas were reported, with a calculated incidence of 1:190,000. This incidence is similar to a review from Tryba (3), which estimated the risk of epidural hematoma to be 1:150,000 after epidural blockade and 1:220,000 after subarachnoid block.
We present this case for two reasons. First, the patient’s initial presentation raised the question of other possible diagnoses after outpatient spinal or epidural anesthesia. Transient neurologic symptoms (TNS) include back pain radiating to the buttocks or legs and most often follow spinal anesthesia with lidocaine (4). Cases of TNS after epidural anesthesia have been reported as well (5). The onset of this syndrome is usually several hours after resolution of the anesthetic. However, it is not associated with motor weakness. A more potentially confusing syndrome is the back pain associated with resolution of chloroprocaine epidural anesthesia (6). This back pain does have immediate onset, but again it is not associated with motor weakness.
The second issue this case raises is our use of ketorolac. Risk factors for the development of epidural hematoma include coagulopathy and traumatic needle insertion. Our patient received two doses of ketorolac, a nonsteroidal antiinflammatory drug, during her operative and immediate postoperative course. In otherwise healthy patients, this does not seem to represent a significant risk for hematoma formation (7,8). Gerancher et al. (9) described a case of postdural puncture spinal hematoma in a 66-year-old patient who had received several doses of ketorolac, but implication of the drug was complicated by difficult needle placement and postoperative thrombocytopenia. Although epidural needle placement was atraumatic in our case, the catheter did puncture an epidural vessel. A prospective study by Horlocker et al. (8) showed no increase in major (spinal hematoma) or minor (blood during needle or catheter placement) hemorrhagic complications from regional anesthesia in patients receiving preoperative antiplatelet therapy. The role of perioperative nonsteroidal medication use after minor hemorrhagic complications, as in our patient, remains unclear.
In summary, we report a patient with acute epidural hematoma who presented with back pain and delayed motor weakness after discharge from an outpatient knee arthroscopy performed with a chloroprocaine epidural anesthetic. Prompt diagnosis and intervention allowed for nearly full recovery. Practitioners should be aware of this rare complication, which can occur in the absence of obvious risk factors and which may be confused with other sources of back pain in the outpatient setting, such as TNS, chloroprocaine back pain, and incisional or positional pain.
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References
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Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.[Free Full Text]
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Wulf H. Epidural anaesthesia and spinal hematoma. Can J Anaesth 1996; 43: 1260–71.[Abstract/Free Full Text]
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Tryba M. Epidural regional anesthesia and low molecular heparin: pro [in German]. Anasthesiol Intensivmed Notfallmed Schmerzther 1993; 28: 179–81.[Medline]
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Freedman JM, Li DK, Drasner K, et al. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1,863 patients. Anesthesiology 1998; 89: 633–41.[ISI][Medline]
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Stevens RA, Urmey WF, Urquhart BL, et al. Back pain after epidural anesthesia with chloroprocaine. Anesthesiology 1993; 78: 492–7.[ISI][Medline]
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Urmey WF, Rowlingson J. Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth Pain Med 1998; 23: 146–51.[ISI][Medline]
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Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995; 80: 303–9.[Abstract]
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Gerancher JC, Waterer R, Middleton J. Transient paraparesis after postdural puncture spinal hematoma in a patient receiving ketorolac. Anesthesiology 1997; 86: 490–4.[ISI][Medline]
Accepted for publication August 22, 2001.
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