| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
Department of Anesthesia and Intensive Care Department of Obstetric and Gynecology Department of Anesthesia and Intensive Care Department of Neurosurgery Department of Obstetrics and Gynecology Department of Anesthesia and Intensive Care, Hôpital Beaujon, University Xavier Bichat, Clichy, France
To the Editor:
We managed a case of suspected spinal hematoma (SH) after a failed attempt of epidural analgesia during labor.
A 32-year old multiparous woman was admitted at 38 weeks’ gestation for left iliac vein thrombosis and was treated with Enoxaparin 70 mg twice daily that was switched to continuous IV unfractionated heparin 5 days later (activated partial thromboplastin time [aPTT]: 54 s [normal value < 40 s]). At the end of the 39th week, heparin was discontinued and labor was induced with oxytocin. Four hours after heparin discontinuation, aPTT was 31 s. After informed consent and at the patient request, epidural placement was attempted at the L3–4 interspace in the sitting position, 6 hours after heparin discontinuation. Direction of the needle was changed four times before epidural space could be located. A multihole flexible epidural catheter (18-gauge, no inside leader, Portex Ltd, Keene, U.S.) was introduced 4 cm cephalad in the epidural space. A frank blood tap was immediately observed in the catheter, which prompted both catheter and needle removal. The patient wished to rest for a moment, and no further attempt of epidural analgesia was done. One hour later, she complained for severe back pain located at the L3–4 interspace with bilateral and cephalic radiation, suggesting radicular back pain. Pain was constant, not altered by uterine contraction and clearly differentiated by the patient from uterine contraction. Pain was unchanged by vertebral palpation and no sensory or motor deficit was observed. No symptom of subarachnoid hemorrhage was found. Epidural hematoma was suspected. After a neurosurgeon’s advice was obtained, it was decided, in order to reduce the delay before spinal imaging and eventually surgery, to perform emergent C-section under general anesthesia after patient information and consent. Magnetic resonance imaging (MRI), done 4 h after back pain onset, ruled out SH. Backache decreased progressively and disappeared in 6 h. Neurological examination remained normal. Enoxaparin (70 mg twice daily) was reintroduced 18 h after the failed epidural. Postpartum period was uneventful with normal neurological status.
Confirmation of SH by specific imaging is an emergency, since neurological prognosis of SH depends on the delay between SH symptoms and decompressive laminectomy (1–3). Classical features of SH (i.e., backache, cauda equina syndrome) can be masked by neuraxial block and diagnosis is commonly suspected in face of unusual recovery from neuroaxial block. In our case, we had to manage a suspected SH very early during labor as epidural analgesia was abandoned. The benefit/risk ratio of three strategies were analyzed. Immediate MRI was considered, but was found not possible because of the problem to obtain several minutes of stillness in a laboring woman without analgesia. To expedite vaginal delivery and perform MRI just after was not considered appropriate, as the duration of labor is unpredictable, leading to an unacceptable delay in SH diagnosis. Furthermore, SH extension may be favored by both uterine contractions and pushing efforts that lead to epidural venous plexus congestion. The strategy we choose gives the advantage to reduce the delay before MRI to 4 h, and to limit the duration of uterine contractions and avoid pushing efforts, but was balanced with a fivefold increase in the perioperative risk of C-section under general anesthesia as compared with vaginal delivery (4). This case emphasizes the difficulty to analyze back pain during labor and the problem of early SH diagnosis on clinical symptoms only.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
