Anesth Analg 2004;98:1181-1183
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000101989.54746.4E
REGIONAL ANESTHESIA
Epidural Hematoma After Spinal Anesthesia in a Patient with Undiagnosed Epidural Lymphoma
André Gottschalk, MD*,
Petra Bischoff, MD*,
Katrin Lamszus, MD
, and
Thomas Standl, MD*
Departments of *Anesthesiology and
Neurosurgery, University Hospital Hamburg-Eppendorf, Germany
Address correspondence to André Gottschalk, MD, Department of Anesthesiology, University Hospital Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Address email to gottschalk.andre{at}gmx.de
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Abstract
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The incidence of hemorrhagic complications after neuroaxial anesthesia is very infrequent. We report a case of a woman developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia at the lumbar level L3-4 for removal of a wire loop in her left knee. No hemostasis altering medication had been taken before and after spinal puncture. The hematoma presenting at the lumbar level L2-3 had to be removed via laminectomy. Pathological examination of the hematoma revealed a highly vascularized centroblastic non-Hodgkin’s lymphoma that was not diagnosed before surgery. The patient did not develop any neurological deficits.
IMPLICATIONS: We report a case of a women developing epidural bleeding 3 wk after performing an uneventful spinal anesthesia for removal of a wire loop in her left knee. Pathological examination of the neurosurgically removed hematoma revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma.
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Introduction
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Predisposing factors for the development of an epidural hematoma are preexisting coagulopathy, spinal vascular malformation, hypertension, therapeutic thrombolysis, and the use of antiplatelet or anticoagulant therapy (1–4). In addition, spinal hematomas are associated with the administration of any kind of neuroaxial anesthesia. The estimated incidence of hemorrhagic complications after epidural anesthesia is between 1:150000 and 1:190000, and after spinal anesthesia it is <1:220000 (5,6). Although spinal bleeding after regional anesthesia is infrequent, the consequences of epidural hematomas are serious and can result in persistent paraplegia. Reasons for epidural hematomas associated with neuroaxial blockade are mainly anatomic abnormalities, traumatic puncture with multiple attempts, and coagulation disorders or anticoagulation therapy (5). We report a case of a woman developing epidural bleeding 3 wk after uneventful spinal anesthesia for removal of a wire loop in her left knee. The hematoma was removed via a laminectomy. Pathological examination revealed a highly vascularized epidural centroblastic non-Hodgkin lymphoma, which was not diagnosed before surgery.
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Case Report
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A 49-yr-old woman (height, 161 cm; weight, 56 kg) was scheduled to undergo removal of a wire loop in her left knee. The wire loop had been used for fixation of an avulsion injury of the anterior cruciate ligament while skiing 1 yr before. The operation was performed under general anesthesia. The intervention was indicated because of pain and pressure sensibility at the insertion of the patellar ligament. Medical history of the patient was unremarkable except for mastectomy because of a carcinoma 5 yr earlier.
Laboratory variables, including coagulation variables, were within in the normal range, with an activated partial thromboplastin time of 32 s (normal range, 25–38 s), international normalized ratio of 1.2 (normal range, 0.85–1.15), and a thrombocyte count of 233 Mrd/L (normal range, 150–450 Mrd/L), and no kind of hemostasis altering medication was used before spinal anesthesia. The patient was seen the day before the operation by a staff anesthesiologist and was scheduled to undergo single-dose spinal anesthesia. The patient was orally premedicated with 7.5 mg midazolam 1 h before induction of spinal anesthesia on the day of surgery. No anticoagulant medication was given during the whole stay in hospital. After performing local anesthesia of the skin with 5 mL of lidocaine 1%, spinal anesthesia was performed by a staff anesthesiologist at the L3-L4 interspace using a 26-gauge Quincke needle with a guide cannula (Portex, Kent, England). Puncture was successful at first attempt showing clear cerebral spinal fluid in the hub of the needle. Plain bupivacaine 0.5%, 2.5 mL was injected in the subarachnoid space resulting in sensory and motor block at T8. The operation was performed within 40 min, the sensory and motor block persisted until 2 h postoperatively but regressed rapidly after that time. Subsequently, the patient was discharged from the postanesthesia care unit to the surgical ward without any sensory or motor deficits or other problems. One day later the patient was discharged from hospital.
Three weeks after discharge from hospital the patient suffered from mild but increasing back pain, especially during exertion. The patient made no connection between her back pain and any specific event. A few days later the pain started to radiate into both legs, especially in the lumbar dermatomes 2–5. Initially no special treatment was performed, but the patient presented to our clinic with increasing pain 7 wk after the operation. The clinical neurological examination revealed no paralysis or dysesthesia. However, a magnetic resonance detected an epidural hematoma at L2-3 with compression of the spinal cord. Under assumption of an epidural hematoma caused by spinal anesthesia, lumbar decompression and removal of the hematoma was performed by laminectomy at L2-3 under general anesthesia. Postoperatively, the back pain was resolved and the patient was discharged 6 days after the operation without further neurological problems or persisting pain.
Pathological examination of the resected hematoma revealed a diffusely infiltrating, unstructured, highly cellular, and densely vascularized tumor (Fig. 1). Perivascular cuffing and infiltration of blood vessels walls by tumor cells was observed. Infiltration and therefore destruction of the blood vessels was the reason for bleeding in the tumor. Among the anaplastic tumor cells, centroblastic, immunoblastic and centrocytic cells as well as numerous mature lymphocytes could be discerned. The tumor cells were immunoreactive for CD20 and the fraction of proliferating cells exceeded 90% (MIB-1 labeling). The tumor was classified as a large B-cell non-Hodgkin’s lymphoma.
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Discussion
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Given the multiple benefits of regional anesthesia, these techniques are often used and will probably be performed by more anesthesiologists in the future (7). Although major complications after neuroaxial blockades are rare, the development of an epidural hematoma can cause major and irreversible complications, such as cauda equina syndrome and paraplegia. The risk for epidural bleeding after neuroaxial blockade is the subject of continuing discussion in editorials, especially when the new anticoagulants are considered (8–10). Among these anticoagulants are the very potent platelet aggregation inhibitors (e.g., ticlopidin), thrombin antagonists (e.g., melagatran), and factor Xa inhibitors (e.g., fondaparinux), and their increasing clinical use will undoubtedly initiate further discussion (10).
Our present case report describes the case of a female patient undergoing elective surgery under spinal anesthesia where there was no apparent increased risk for spinal bleeding. Spinal puncture with a 26-gauge needle was completely uneventful and the course of spinal anesthesia (spread and regression) was unremarkable.
Non-Hodgkin’s lymphoma was not diagnosed as the possible cause for spinal bleeding and the hematoma until the histopathological examination was finished. The incidence of spinal spread among patients with non-Hodgkin’s lymphoma ranges from 0.1%–6.5% with increasing numbers at an advanced stage of the disease (11). Apart from children, patients with spinal spread of lymphoma are mainly at advanced age. As an initial symptom, the spinal epidural manifestation of the disease is extremely rare, with only a few cases reported in the literature (12,13).
Although a non-Hodgkin’s lymphoma was diagnosed in this patient, the reason for the epidural hematoma in our patient remained unclear. As the pathological examination showed a highly vascularized lymphoma, a spontaneous rupture of one of the tumor-infiltrated blood vessels was possible. As the spinal puncture was performed between the lumbar levels 3 and 4 and the hematoma/lymphoma was detected at the level of the lumbar vertebral bodies 2 and 3, this may be a possible explanation. However, it is possible that the spinal puncture documented with a puncture at L3-4 by the staff anesthesiologist was in fact performed at the L2-3 interspace. A study by Furness et al. (14) showed that using the method of palpating the iliac crest to identify L3, the lumbar intervertebral level of the puncture site is one level above or below the assumed level in 70% of the cases. If indeed the puncture was performed between L2 and L3 in our patient, needle placement into the lymphoma cannot be excluded. However, it still remains unclear why the epidural hematoma became symptomatic 3 weeks after the patient’s discharge from hospital or why the bleeding did not stop spontaneously in the absence of anticoagulants or any coagulation disorder. Paraneoplastic dysfunction of the thrombocytes cannot be excluded and may have contributed to the development of the epidural bleeding.
In patients suffering from any kind of lymphoma, the anesthesiologist needs to be aware of the possibility of the existence of a spinal epidural spread of the lymphoma that can cause spinal bleeding and hematoma. For this reason, in these patients, peripheral nerve blockade should be considered or even preferred for lower extremity surgery.
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References
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Accepted for publication October 1, 2003.
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Abstract
Introduction
blood vessel).
