Spinal subdural bleeding after attempted epidural and subsequent spinal anaesthesia in a patient on thromboprophylaxis with low molecular weight heparin

Abstract

Despite the extensive use of low molecular weight heparins (LMWH) for thromboprophylaxis, only two serious complications have thus far been reported where spinal haematomas were incurred after epidural and spinal blocks in patients on such treatment. In our patient, who was on thromboprophylaxis with the LMWH drug enoxaparin, catheter epidural anaesthesia was abandoned due to a bloody tap and superseded by spinal anaesthesia. More than 40 hours later she had developed a paraparesis and complete sensory loss in the lower extremities. The MRT image showed haematomas epi- and subdurally, as well as subarachnoidally, but no epidural bleeding was seen at laminectomy.

Influence of posture on the incidence of vein cannulation during epidural catheter placement

“…The introduction of routine postoperative thromboprophylaxis, especially with low-molecularweight heparins, has led to an increase in the incidence of epidural haematoma being reported. Enoxaparin, for example, has been implicated in epidural haematoma in patients following epidural catheter removal, particularly when a bloody tap has been noted at the time of insertion [13,14]. Engorgement of the plexus of epidural veins secondary to the effects of gravity and caval obstruction by the gravid uterus are the most likely explanation for our high rate of blood tap in the sitting position.…”

Epidural anaesthesia and spinal haematoma

“…Less information exists relating to the incidence of these complications following treatment with the newer, low molecular weight heparins 41,62,63,88,96 but since the risk of other (surgical) bleeding complications such as wound haematoma is not increased in comparison with the use of unfractionated heparin, 97 it is unlikely that low molecular weight heparins present a special risk. It can be concluded from this analysis of case reports, that the combination of low dose heparin or NSAID with epidural anaesthesia is safe clinical practice.…”

Acute spontaneous spinal subdural haematoma presenting as paraplegia and complete recovery with non-operative treatment

“…Their development may be related to a variety of factors: anticoagulant therapy, coagulopathies (idiopathic thrombocytopenic purpura,13 polycythaemia,14 leukaemia and severe liver failure15) and after poisoning with rodenticides of the coumarin group 8. SSH is a recognised but statistically rare complication in patients given spinal anaesthesia 16 – 20. There are risk factors for this condition: traumatic spinal lumbar puncture, multiple spinal punctures,1 , 15 particularly needles that stray from the midline,21 peridural catheterisation, coagulopathy14 or anticoagulant therapy,22 and the venous dilatation that occurs at the end of pregnancy 21.…”