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

Abstract

P Pu ur rp po os se e: : 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.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : 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.C Co on nc cl lu us si io on n: : 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. PINAL epidural hematoma is a rare complication of epidural anesthesia with an estimated incidence of 1:190,000 and potentially devastating consequences. 1 Identified risk factors include difficult or traumatic needle/catheter insertion, ankylosing spondylitis, and anticoagulation/coagulopathy 1,2 whereas treatment with low-dose unfractionated heparin is generally considered safe. 3 Typical presentation is with sharp back pain and associated motor and sensory deficit progressing to paraplegia, with a poor prognosis of recovery if decompressive laminectomy is not performed within eight hours. Here, we report a case of spinal epidural hematoma in a 90-yr-old patient with no history of coagulopathy, multiple/traumatic needle insertion or catheter manipulation who received low-dose sc unfractionated heparin postoperatively in accordance with current standard guidelines, presented with no back pain, and made full neurologic recovery without surgical intervention. ObjectifC Ca as se e r re ep po or rt t A 90-yr-old Caucasian female [weight, 57 kg; American Society of Anesthesiologists (ASA) physical status class II] presented with gastric adenocarcinoma and was taken to the operating room for subtotal gastrectomy with creation of a Roux-en-Y anastomosis and feeding jejunosto...

Spontaneous complete recovery of paraplegia caused by epidural hematoma complicating epidural anesthesia: a case report and review of literature

“…Some patients have severe local pain in the back as the first symptom, but occasionally the bleeding can be completely painless. 11 Local back pain has been attributed to the stretching of the dura by collected blood. Our patient had severe back pain 2 h before the onset of the weakness.…”

What’s a nice patient like you doing with a complication like this? Diagnosis, prognosis and prevention of spinal hematoma

“…In this issue of the Canadian Journal of Anesthesia, Schwarz et al 6 report a spinal hematoma associated with standard sc heparin thromboprophylaxis in the presence of epidural catheterization. The patient made a full neurologic recovery, despite lack of surgical intervention.…”

“…Interestingly, not all spinal hematomas are treated with emergency laminectomy; spontaneous resolution of deficits has been reported. 6,9 However, the decision to observe vs surgically intervene is a neurosurgical one. H Ha as s s sp pi in na al l h he em ma at to om ma a b be ee en n r re ep po or rt te ed d i in n t th he e p pa ar rt tu ur ri ie en nt t p po op pu ul la at ti io on n?…”

“…6 présentent un cas d'hé-matome rachidien associé à l'administration sc standard d'héparine thromboprophylactique avec un cathéter péridural en place. Le patient a connu une récupération neurologique complète, malgré l'absence d'intervention chirurgicale.…”

“…Rappelons que tous les hématomes rachidiens ne sont pas traités par laminectomie ; la résolution spontanée des déficits a déjà été signalée. 6,9 La décision, d'observer vs d'intervenir chirurgicalement, appartient au neurochirurgien. L L' 'h hé ém ma at to om me e r ra ac ch hi id di ie en n e es st t--i il l r ra ap pp po or rt té é d da an ns s l la a p po op pu ul la a--t ti io on n o ob bs st té ét tr ri ic ca al le e ?…”