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Spontaneous recovery from a spinal epidural hematoma with atypical presentation in a nonagenarian

[La récupération spontanée après un hématome épidural rachidien de présentation atypique chez une nonagénaire]

Stephan K.W. Schwarz, MD DR Med PhD^*, Clinton L. Wong, MD FRCPC and William N. McDonald, BSc MD FRCPC

^* From the Centre for Anesthesia and Analgesia, Department of Anesthesia and Department of Pharmacology and Therapeutics, The University of British Columbia; and
the Division of Acute and Interventional Pain Management, Department of Anesthesia, St. Paul’s Hospital, Vancouver, British Columbia, Canada.

Address correspondence to: Dr. Stephan Schwarz, Department of Pharmacology and Therapeutics, The University of British Columbia, 2176 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada. Phone: 604-822-5565; Fax: 604-822-6012; E-mail: Schwarz{at}neuro.pharmacology.ubc.ca

Purpose: Spinal epidural hematoma following epidural anesthesia is extraordinarily rare in association with low-dose sc heparin, and the prognosis for neurologic recovery without rapid surgical decompression poor. We report a case of spinal epidural hematoma in a nonagenarian who received low-dose sc unfractionated heparin postoperatively in accordance with standard guidelines, presented with no back pain, and made full neurologic recovery without surgical intervention.

Clinical features: A 90-yr-old female with gastric adenocarcinoma presented for subtotal gastrectomy. Her past medical history and physical examination were largely unremarkable and she had no bleeding diathesis. She took no medications other than preoperative ranitidine, and had a normal coagulation profile. A thoracic epidural catheter was placed uneventfully before induction of general anesthesia. Postoperatively, low-dose sc unfractionated heparin was started 12 hr after the epidural catheter insertion. On postoperative day two, the patient developed flaccid lower extremity paralysis and paresthesia without back pain. Her coagulation profile remained normal. Subsequent magnetic resonance imaging showed a large epidural hematoma extending from T3 to T11. With conservative treatment and no surgery, the patient slowly made full neurologic recovery and was discharged home on postoperative day 56.

Conclusion: Complete neurologic recovery from flaccid paralysis following spinal epidural hematoma occurred without surgical decompression in a nonagenarian. Low-dose sc heparin may be a greater risk factor for spinal epidural hematoma than previously assumed, and the absence of back pain does not rule out this diagnosis.

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