+

Epidural Hematoma

Jen SackrisonAnesthesia Clerkship9/2/11

+Etiologies3

Epidural catheter anesthesia

Spontaneous

Trauma

Spinal surgery

The proposed source of blood is the epidural venous plexus or the “Batson’s plexus” – it is not thought to be arterial in origin.

Figure 3.  Anatomic drawing of the vertebral venous system.

Umeoka S et al. Radiographics 2004;24:193-208

©2004 by Radiological Society of North America

+Incidence Associated with Neuraxial Block1

Rare complication

<1 in 150,000 epidural anesthetics

< 1 in 220,000 spinal anesthetics

+Proposed Risk Factors2

Old age

Spinal stenosis

Coagulopathy

Anti-coagulant therapy3

Platelet dysfunction/inhibition

AVM

Multiple punctures/difficult placement

Ankylosing spondylitis3

+Clinical Presentation

Can be asymptomatic1,2,3

Cauda equina syndrome1,2,3: Back pain Progressive

numbness/weakness Loss of normal bladder

and bowel function

Timeline = generally acute3

Can present as late as 9 days or even 6 weeks2,3

+Diagnosis/Tx

Neuro exam

MRI2

Dexamethasone2

Immediate surgical decompression2

Surgery must be performed within 8 hrs to prevent permanent damage1

+Example MRI2

+Neuraxial block and Heparin1

Safe intraop using standard Heparin when… Catheters placed one 1 hr prior to heparinzation Catheters are removed at low heparin levels Heparin is not used in conjunction with other anticoagulants,

thrombolytics or anti-platelet drugs

Avoid neuraxial block when IV standard therapeutic heparin is prolonged

No contraindication for neuraxial block and SQ heparin

Timing of placement of block with LMWH is very important: placement of catheter 24 hrs prior to first dose and removal of catheter 10-12 hrs after last dose

+Neuraxial block and other anticoagulants/anti-platelet drugs1 Generally not recommended for orally anticoagulated

patients (i.e. Warfarin)

No significant risk with anti-platelet drugs

+References

1. Horlocker, T. T. (2000). Complications of spinal and epidural anesthesia. Anesthesiology Clinics of North America. 18(2):

2. Guffey, P.J., McKay, W.R., McKay, R.E. (2010). Epidural hematoma nine days after removal of a labor epidural catheter. Anesthesia Analgesia. 111(4): 992-995.

3. Boco, T. and Deutsch, H. (2007). Delayed symptomatic presentation of epidural hematoma after epidural catheter anesthesia. Spine. 32(22): E649-E 651.