Indian Journal of Anaesthesia

BRIEF COMMUNICATION
Year
: 2016  |  Volume : 60  |  Issue : 5  |  Page : 355--357

Spinal epidural haematoma following removal of epidural catheter after an elective intra-abdominal surgery


Sudeep Mahapatra1, NS Chandrasekhara1, Surjya Prasad Upadhyay2,  
1 Department of Anaesthesiology, Sagar Hospital, Bengaluru, Karnataka, India
2 Department of Anaesthesiology, NMC Hospital, Dubai Investment Park, Dubai, United Arab Emirates

Correspondence Address:
Surjya Prasad Upadhyay
NMC Hospital, Dubai Investment Park, Dubai
United Arab Emirates




How to cite this article:
Mahapatra S, Chandrasekhara N S, Upadhyay SP. Spinal epidural haematoma following removal of epidural catheter after an elective intra-abdominal surgery.Indian J Anaesth 2016;60:355-357


How to cite this URL:
Mahapatra S, Chandrasekhara N S, Upadhyay SP. Spinal epidural haematoma following removal of epidural catheter after an elective intra-abdominal surgery. Indian J Anaesth [serial online] 2016 [cited 2020 Nov 23 ];60:355-357
Available from: https://www.ijaweb.org/text.asp?2016/60/5/355/181610


Full Text

 INTRODUCTION



Although epidural catheters are effective for post-operative analgesia, [1] they are not free of risks. A rare complication of catheter-based epidural analgesia is bleeding within the epidural space resulting in the formation of a spinal epidural haematoma (SEH) with neurological deficits. We encountered a case of epidural haematoma and lower limb paresis following removal of epidural catheter in post-operative period.

 CASE REPORT



An 86-year-old female weighing 58 kg, with controlled hypertension underwent elective choledochoduodenostomy under general anaesthesia with endotracheal intubation. Before induction of general anaesthesia, an epidural catheter was inserted uneventfully at T7-8 intervertebral level using 18 gauge Tuohy needle with 20 Gauge catheter; epidural space was identified using loss of resistance to air in the first attempt, with no blood seen through epidural needle and catheter. A test dose of 3 ml 2% lignocaine with adrenaline 1:200,000 was used to test to exclude intravascular and intrathecal placement of epidural catheter. Pre-operative investigations were within normal limits including creatinine (0.97 mg/dl), prothrombin time, activated partial thromboplastin time and platelet count.

Post-operative analgesia was provided with continuous epidural infusion of bupivacaine 0.125% along with fentanyl 2 μg/ml at the rate of 4-8 ml/h. Mechanical thromboprophylaxis (pneumatic pump) was started pre-operatively with addition of a single daily dose of fractionated heparin (dalteparin sodium 2500 U) subcutaneously after 12 h post-operatively. Post-operative course was uneventful. On the 4 th post-operative day, 12 h after the last dose of fractionated heparin, the epidural catheter was removed. Four hours after removal of the epidural catheter, the patient complained of severe backache with radiating pain and weakness in the lower limbs. Clinical examination revealed hypoesthesia and muscle power of grade 3/5 in the left lower limb and 4/5 in the right lower limb. With a high index of suspicion for SEH causing spinal cord compression, the patient was started on intravenous (IV) methylprednisolone, and further dosage of heparin was withheld. A magnetic resonant imaging (MRI) scan was deferred after discussion with radiologist and surgeon as the patient had staples at skin incision site. Computed tomography thorax was done which revealed partial collapse of L1-3 vertebrae, and vague intraspinal soft tissue lesion in L1 extending to T11-L2 level. On the 6 th post-operative day (48 h after symptoms were noted) after removing the skin staples, an MRI scan was done. MRI revealed epidural haematoma at T11-L1 level with cord compression with no significant cord lesion [Figure 1] and [Figure 2].{Figure 1}{Figure 2}

The patient was taken up for emergency laminectomy and decompression under general anaesthesia. The haematoma was meticulously evacuated, and no active bleeding vessel could be identified.

Her neurological status remained unchanged for first 2 days; however, the radiating pain had disappeared. On the 3 rd post-operative day, improvement in muscle power was seen. On the 5 th post-operative day, the patient regained normal muscle power of both lower limbs. She was discharged home on the 6 th post-operative day; subsequent follow-up on weekly basis did not reveal any sensory-motor abnormality.

 DISCUSSION



The incidence of bleeding complications has been previously estimated to occur in 1:150,000 epidurals and 1:220,000 spinal anaesthetics. However, it is highly variable and may be much higher (1:3000 epidurals and 1:40,000 spinal anaesthetics) with concomitant use of heparin. [2],[3],[4],[5]

The symptoms of acute SEH include sudden onset of back pain, often with a radicular character and sensory-motor deficits which outlast the expected duration of epidural or spinal anaesthesia. Symptoms of SEH may be masked by continuous infusion of epidural analgesia. The severity of motor or sensory deficit may be greater than expected when continuous epidural infusion is used. [6],[7],[8]

MRI is the investigation of choice when SEH is suspected after an epidural placement or removal. In the present case, MRI could not be done as first line investigation, as the patient had skin staples. It was performed when deemed permissible, i.e., after removing the skin staples. The epidural needle insertion site was T7-8 space; the downward extension of haematoma in T11-L 1 could be due to injury to any vessels by downward migration of epidural catheter during insertion or removal. [7] The patient was put on methylprednisolone after the advice of neurosurgeon; treatment was initiated as per the protocol of traumatic spinal cord injury although the evidence for it use is poor and often questionable. [8]

Once a definitive diagnosis has been made, urgent surgical decompression is the accepted standard of care in the vast majority of cases. This usually requires laminectomy and evacuation of the haematoma, [6],[7] which was carried out in our case. In the recent years, there have been several case reports of SEH, which have been followed conservatively, without surgical intervention and with favourable neurological outcomes. [9],[10] Most studies have found a clear trend of better outcomes in those patients who underwent operative intervention early (within 6 h of symptoms) and in those patients presenting with less severe deficits. [10],[11]

In our case, the time interval between symptom onset and surgery was more than 24 h, but still the patient had a satisfactory recovery. It has been previously shown experimentally that functional recovery in cats following spinal cord compression was associated with demyelination of the spinal cord white matter. [11] Therefore, the patients who recover after surgery probably had a demyelinating lesion, whereas patient who does not recover may have axonal disruption.

Recent guideline from American Society of Regional Anesthesia recommend the minimum timing of epidural placement and removal as follows: [12]

4 h after IV unfractionated heparin, can be restarted 2 h after placement/removal of catheter8-10 h for subcutaneous heparin12 h for subcutaneous fractionated heparin; can restart after 4 h of epidural placement/removal.

Development of epidural haematoma after removal of the catheter in our case may have been caused by the use of fractionated heparin (dalteparin 2500 units), although the time interval from the last dose of dalteparin to the removal of catheter was 12 h.

Although the serum creatinine seems to be in normal range (0.97 mg/dl), but its value may be misleading specially in elderly with reduced muscle mass where the creatinine production as such is very low and the estimated creatinine clearance by Cockcroft-Gault equation was just 39.3 ml/min. This might have prolonged the elimination of fractionated heparin, and sufficient level of anticoagulant activity was still present when the catheter was removed. This complication might have been averted if the catheter removal had been done after 24 h of the last dose of dalteparin or use of unfractionated heparin in the presence of reduced creatinine clearance which does not depend on renal clearance for elimination.

 CONCLUSION



Occurrence of spinal epidural haematoma may be attributed to longer duration of action of fractionated heparin in elderly patients with impaired creatinine clearance. Delaying catheter removal for 24 rather than 12 h after the last dose of heparin may be the more appropriate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Nimmo SN, Harrington LS. What is the role of epidural analgesia in abdominal surgery? Contin Educ Anaesth Crit Care Pain 2014;14:224-9.
2Tryba M. Epidural regional anesthesia and low molecular heparin: Pro. Anasthesiol Intensivmed Notfallmed Schmerzther 1993;28:179-81.
3Horlocker TT, Heit JA. Low molecular weight heparin: Biochemistry, pharmacology, perioperative prophylaxis regimens and guidelines for regional anesthetic management. Reg Anesth Pain Med 1998;23 6 Suppl 2:164-77.
4Schroeder DR. Statistics: Detecting a rare adverse drug reaction using spontaneous reports. Reg Anesth Pain Med 1998;23 6 Suppl 2:183-9.
5Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165-77.
6Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: Relationship between surgical timing and neurological outcome. J Neurosurg 1995;83:1-7.
7Miyazaki M, Takasita M, Matsumoto H, Sonoda H, Tsumura H, Torisu T. Spinal epidural hematoma after removal of an epidural catheter: Case report and review of the literature. J Spinal Disord Tech 2005;18:547-51.
8Sansam KA. Controversies in the management of traumatic spinal cord injury. Clin Med (Lond) 2006;6:202-4.
9Herbstreit F, Kienbaum P, Merguet P, Peters J. Conservative treatment of paraplegia after removal of an epidural catheter during low-molecular-weight heparin treatment. Anesthesiology 2002;97:733-4.
10La Rosa G, d′Avella D, Conti A, Cardali S, La Torre D, Cacciola F, et al. Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases. J Neurosurg 1999;91 1 Suppl: 128-32.
11Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: A study of the factors determining postoperative outcome. Neurosurgery 1996;39:494-508.
12Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015;40:182-212.