Spinal subdural haematoma in a parturient after attempted epidural anaesthesia

Abstract

We report a case of spinal subdural haematoma with neurological deficit in a 36-yr-old woman following Caesarean section for severe preeclampsia and placental abruption. She had been taking chronic trifluoperazine treatment for depression. Her activated partial thromboplastin time (aPTT) was 49 sec (normal = 26-36) but all other tests of coagulation were normal Epidural anaesthesia was attempted but, despite a negative test dose, injection of local anaesthetic resulted in a generalizedSpinal haematoma, occurring either spontaneously or after regional block can result in severe, permanent neurological deficit. However, this complication is exceedingly rare. There are no case reports of spinal haematoma associated with epidural anaesthesia in a parturient without antecedent lumbar pathology. ~ This report describes the occurrence of a spinal subdural haematoma after attempted epidural anaesthesia in a parturient with severe preeclampsia. Case reportA 36-yr-old, 60 kg, gravida 3, para 2 woman presented at 30.5 wk gestation with severe preeclampsia. Her medical history before pregnancy was unremarkable except for an unspecified psychiatric illness for which she was treated with trifluoperazine. There was no history of a bleeding disorder. Examination of the medical records from the transferring hospital revealed that the patient had complained of severe back pain radiating down both legs which was not associated with any neurological deficit. This lasted about six hours and had resolved before she was transferred to our hospital for management of severe preeclampsia. Upon arrival, her blood pressure was 160/100 mmHg and four plus proteinuria was found on dipstick examination. Serum electrolytes, uric acid and CAN J ANAESTH 1993 / 40:4 / pp M0-5Lao el al.: SPINAL HAEMATOMA 341 liver enzymes were normal except for elevated alkaline phosphatase of 880 IU (normal range, 38-110). Her haemoglobin concentration was 121 g. L -I. She had a normal prothrombin time (PT, 10.5 see), bleeding time (three minutes), and fibrinogen (7.66 g-L-l). The fibrin split products were marginally elevated (20 mg-L -1, normal = < 10). The platelet count was 425,000. mm -3, activated partial thromboplastin time (aPTT) was prolonged to 49 sec (n = 24-36). The patient's blood pressure remained elevated in spite of continued treatment with magnesium sulphate and parenteral hydralazine. Ten hours later she had a small vaginal bleed, which suggested the diagnosis of placental abruption. She was prepared for an urgent Caesarean section under epidural anaesthesia. On arrival in the operating room her blood pressure was 150/100 mmHg. While monitoring the patient with a pulse oximeter, ECG, and automatic blood pressure cuff, a 20-gauge epidural catheter was placed atraumatically through a 17-ga Tuohy needle at the I..2-L 3 interspace. Following a negative aspiration test, a three ml test dose of lidocaine hydrocarbonate 2% with five 0-g" ml -~ epinephrine was given without change in blood pressure or heart rate. A further 5 ml of the same solution was t...

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

“…Magnetic resonance imaging (MRI) after epidural blood patch revealed blood leaking out through the intravertebral foramina after injection in young individuals. 273 Until 2011, all case reports of neuraxial hematomas in obstetric patients with altered hemostasis have occurred in parturients with a preexisting coagulopathy (eg, thrombocytopenia, hemorrhage, preeclampsia, thrombocytopenia, HELLP) at the time of either epidural placement or removal 42,47,269,[274][275][276][277][278][279][280][281][282][283][284] (Table 17). There are 2 recent cases of spinal hematoma involving LMWH and neuraxial anesthesia in obstetric patients: in one, the patient received therapeutic anticoagulation (enoxaparin 1 mg/kg BID) for a postpartum pulmonary embolus 3 days after a cesarean delivery performed with a spinal catheter.…”

Anesthetic practices for patients with preeclampsia or HELLP syndrome: A survey

“…Third, most spinal epidural hematomas occurred in patients with HELLP syndrome and not preeclampsia with no evidence of HELLP syndrome (5,(21)(22)(23). Moreover, epidural anesthesia was the preferred method in those complicated cases (24,25). Vigil-De Gracia and colleagues reported 36 patients with HELLP syndrome with platelet counts below 100,000/µL who received regional anesthesia and no epidural hematoma was suffered by any of the patients (12 patients had platelet counts below 50,000/µL) (26).…”

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

“…SSHs may be associated with subarachnoid haemorrhage, manifesting with elevated intracranial pressure13 , 24 or with subdural intracranial haematoma25 – 28 occurring after mild cranial trauma. Rader29 proposed that a forgotten effort or minor trauma can increase both the intrathoracic and intraluminal pressure of the vessels traversing the subarachnoid space.…”