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* 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
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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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Before induction of general anesthesia, a 19-G thoracic epidural catheter (FlexTip Plus®, Arrow International, Inc., Reading, PA, USA) was placed at T8/9 on the first attempt under aseptic conditions with the patient sitting, using a "loss of resistance" technique with a 17-G Tuohy needle inserted via a left paramedian approach. There was no history of traumatic needle insertion or paresthesia, nor were cerebrospinal fluid (CSF) or blood aspirated. The epidural catheter was easily advanced 5 cm into the epidural space and a test dose of 3 mL lidocaine 2% administered without incident. Following uneventful induction of general anesthesia, combined general and regional anesthesia was maintained with desflurane and nitrous oxide in oxygen and a total epidural dose of 100 µg fentanyl, 1 mg preservative-free morphine, and 23 mL bupivacaine 0.25% throughout the 2.5 hr procedure. A Foley catheter inserted after induction of anesthesia. The patient was stable intraoperatively and no adverse events were noted. The surgical team found that the tumour had infiltrated surrounding tissues including the pancreas and completed the procedure with palliative intent. Intraoperative blood loss was estimated at 200 mL and no blood products were administered. Hemostasis was satisfactory with no clinical evidence of coagulopathy.
Postoperatively, the patient was transferred to a surgical ward where continuous epidural analgesia was maintained with bupivacaine 0.1% and preservative-free morphine 0.05 mg•mL–1, infusing at 5 to 7 mL•hr–1 and producing satisfactory pain relief. A positive motor response of the lower extremities was noted. Low-dose sc unfractionated heparin was started at 5000 IU twice daily, with the first dose administered 12 hr after insertion of the epidural catheter. Other postoperative medication included iv cefazolin, metronidazole, and ranitidine. No antiplatelet drugs were given. The Foley catheter remained in situ. There was no history of epidural catheter manipulation. On the evening of postoperative day two, the patient complained to the surgical house staff of bilateral lower extremity weakness and paresthesia without back pain or chills. This was felt to be due to the epidural infusion, which was held overnight. In the morning of postoperative day three, there was little improvement of the patient’s symptoms. The attending Acute Pain Service anesthesiologist assessed the patient and a neurologist was consulted. Back pain continued to be absent. On physical examination, the patient was afebrile and had normal vital signs. The epidural insertion site was unremarkable except for some mild serosanguinous drainage. Neurologic examination showed markedly reduced muscle tone in both legs. Motor power of the lower extremities was 2/5 in all muscle groups except right ankle dorsiflexors (1/5) and left knee extensors, ankle dorsiflexors, and ankle plantar flexors (3/5). Deep tendon reflexes were absent bilaterally. Sensation to pinprick and light touch was absent below the L2 dermatome on the right and below T12 on the left. There was paresthesia with patches of allodynia to light touch in the area of the L1 dermatome on the right and T12 on the left. A coagulation profile showed a platelet count of 185,000 per mm3, an INR of 1.1, and an aPTT of 32.6 sec. The white blood cell count was 12,600 per mm3 (neutrophil granulocytes, 74%). Urgent magnetic resonance imaging (MRI) of the patient’s thoracic and lumbar spine showed a large epidural hematoma extending from T3 to T11, with no evidence of vascular abnormalities, ischemic changes, or spinal stenosis (Figure
).
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Firstly, spinal epidural hematoma should always be considered early in the differential diagnosis of patients on continuous epidural analgesia who present with motor and sensory deficits. This may represent a diagnostic challenge, since the presence of lower extremity weakness and sensory changes may be interpreted as being due to the local anesthetic infusion, particularly by non-anesthesiologists and in the absence of back pain or inadequate analgesia, as was the case in this patient. Analysis of the ASA closed claims project database supports this diagnostic approach: in at least ten claim files, delayed diagnosis of epidural hematoma was a major factor in the resultant nerve injury.4 It must be re-emphasized that the absence of back pain does not exclude spinal epidural hematoma. In a series of 61 cases reviewed in 1994, back pain was the first symptom in only 38% of patients.2 Aggressive early MRI scanning will lead to early diagnosis in this situation, and such a strategy should be considered standard of care.
Another important differential diagnosis of consideration is intrathecal migration of the epidural catheter, which may produce flaccid lower extremity paralysis due to subarachnoid infusion of local anesthetic solution, often in association with hypotension and/or respiratory compromise. Whereas this diagnosis may be made acutely by aspirating CSF from the epidural catheter, the persistence of the neurologic deficit in the present patient after the epidural infusion had been held overnight was more consistent with spinal epidural hematoma.
A third consideration is anterior spinal artery syndrome, recently reviewed in the literature.5 In addition to the clinical constellation of a sudden onset of flaccid paralysis, areflexia, patchy sensory deficit, and absence of back pain in an elderly patient, the discrepancy between the largely lumbar distribution of the neurologic deficit and the thoracic insertion site of the epidural catheter was noteworthy and appeared to support this possibility. Again, MRI scanning proved to be instrumental in establishing the correct diagnosis.
A final important differential diagnosis is spinal epidural abscess formation, which was considered less likely in this patient given the rapid onset, absence of generalized symptoms including fever, and normal white blood cell count.
Secondly, treatment with low-dose sc unfractionated heparin may have been a predisposing factor. The 2003 consensus statement of the American Society of Regional Anesthesia (ASRA) does not regard low-dose heparin a contraindication to the use of neuraxial anesthesia,3 similar to others in the past.6,7 Nonetheless, there are at least four reported cases of spinal epidural hematoma associated with epidural anesthesia in patients who received low-dose sc unfractionated heparin for prophylaxis of venous thromboembolism.8–10 In addition, at least one case associated with spinal anesthesia has been reported,11 and one after combined spinal epidural anesthesia that manifested following epidural catheter removal.12 However, the question whether patients receiving low-dose heparin truly carry an increased risk of bleeding compared to patients receiving no heparin or placebo remains unanswered. Low-dose sc heparin may produce unpredictable aPTT prolongations;13 in the present patient, however, no postoperative coagulation abnormalities were found. It is of note that the time interval between placement of the epidural catheter and the first dose of heparin was significantly longer than the current ASRA recommendation (12 hr vs 1 hr).
Thirdly, advanced age per se is a risk factor for spinal epidural hematoma.1,2 Until recently, however, it did not appear reasonable to consider advanced age a contraindication for epidural anesthesia in light of the evidence for the potential benefits of this technique compared to general anesthesia alone.14–16 In the last three years, on the other hand, the magnitude of such benefits has come into question,17–19 which may lead clinicians to re-evaluate the risk-benefit analysis of epidural anesthesia in the elderly.
Finally, this case provides the first document to our knowledge of neurologic recovery from spinal epidural hematoma following epidural anesthesia without decompressive laminectomy in a nonagenarian. Persson et al. reported recently on a 74-yr-old patient who had received a thoracic epidural catheter and recovered neurologically despite surgery being delayed for three days after diagnosis.20 Interestingly, several series of cases of recovery without surgery have been reported in the neurosurgical literature in patients who developed spontaneous spinal epidural hematomas without neuraxial anesthesia or lumbar puncture.21–24 This may be a reflection of the epidemiology of this condition, as the vast majority of spinal epidural hematomata occur spontaneously without association with neuraxial anesthesia.1,25 However, such cases represent the exception in the literature, where the prognosis for patients in whom surgical decompression is not performed within eight hours has been poor.1,2,25 In conclusion, we report here the first case of full neurologic recovery without surgery from spinal epidural hematoma following epidural anesthesia in a nonagenarian. The occurrence of this complication in the absence of established risk factors other than age and treatment with low-dose unfractionated heparin as well as its atypical presentation without back pain emphasize the need for clinical vigilance in the routine postoperative care of patients receiving epidural anesthesia.
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Acknowledgments |
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Financial arrangements that could lead to conflict: none.
Accepted for publication September 16, 2003. Revision accepted December 1, 2003.
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2 Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.
3 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 Pain Med 2003; 28: 172–97.[Medline]
4 Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia. A closed claims analysis. Anesthesiology 1999; 90: 1062–9.[Medline]
5 Horlocker TT, Wedel DJ. Neurologic complications of spinal and epidural anesthesia. Reg Anesth Pain Med 2000; 25: 83–98.[Medline]
6 Schwander D, Bachmann F. Heparin and spinal or epidural anaesthesia: clinical decision making (French). Ann Fr Anesth Reanim 1991; 10: 284–96.[Medline]
7 Liu SS, Mulroy MF. Neuraxial anesthesia and analgesia in the presence of standard heparin. Reg Anesth Pain Med 1998; 23(Suppl 2): 157–63.[Medline]
8 Darnat S, Guggiari M, Grob R, Guillaume A, Viars P. Lumbar epidural haematoma following the setting-up of an epidural catheter (French). Ann Fr Anesth Reanim 1986; 5: 550–2.[Medline]
9 Metzger G, Singbartl G. Spinal epidural hematoma following epidural anesthesia versus spontaneous spinal subdural hematoma. Two case reports. Acta Anaesthesiol Scand 1991; 35: 105–7.[Medline]
10 Sandhu H, Morley-Forster P, Spadafora S. Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis. Reg Anesth Pain Med 2000; 25: 72–5.[Medline]
11 Dupeyrat A, Dequire PM, Merouani A, Moullier P, Eid G. Subarachnoid haematoma and spinal anaesthesia (French). Ann Fr Anesth Reanim 1990; 9: 560–2.[Medline]
12 Pay LL, Chiu JW, Thomas E. Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis. Acta Anaesthesiol Scand 2002; 46: 217–20.[Medline]
13 Gallus AS, Hirsh J, Tuttle RJ, et al. Small subcutaneous doses of heparin in prevention of venous thrombosis. N Engl J Med 1973; 288: 545–51.
14 Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987; 66: 729–36.[Medline]
15 Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 6: 1474–506.
16 Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1–12.
17 Park WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg 2001; 234: 560–71.[Medline]
18 Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82.[Medline]
19 Peyton PJ, Myles PS, Silbert BS, Rigg JR, Jamrozik K, Parsons AR. Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Anesth Analg 2003; 96: 548–54.
20 Persson J, Flisberg P, Lundberg J. Thoracic epidural anesthesia and epidural hematoma. Acta Anaesthesiol Scand 2002; 46: 1171–4.[Medline]
21 Silber SH. Complete nonsurgical resolution of a spontaneous spinal epidural hematoma. Am J Emerg Med 1996; 14: 391–3.[Medline]
22 Duffill J, Sparrow OC, Millar J, Barker CS. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases. J Neurol Neurosurg Psychiatry 2000; 69: 816–9.
23 Dam-Hieu P, Mihalescu M, Tadie M. Spontaneous cervico-thoracic epidural hematoma with spontaneously regressive paraplegia (French). Neurochirurgie 2001; 47: 442–4.[Medline]
24 Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases. Spine 2001; 26: E525–7.[Medline]
25 Schmidt A, Nolte H. Subdural and spinal haematomaa following spinal, epidural, or caudal anaesthesia (German). Anaesthesist 1992; 41: 276–84.[Medline]
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T. T. Horlocker What's a nice patient like you doing with a complication like this? Diagnosis, prognosis and prevention of spinal hematoma/Qu'est-ce qu'un patient comme vous fait avec une complication comme celle-la ? Diagnostic, pronostic et prevention d'un hematome rachidien Can J Anesth, June 1, 2004; 51(6): 527 - 534. [Full Text] [PDF]
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