Delayed Subarachnoid Hematoma After Continuous Epidural Anesthesia in a Patient Without Risk Factors: Good Outcome After Late Laminectomy

Abstract

To the Editor: Subarachnoid hematoma is a rare but serious neurological complication of neuraxial anesthesia, with an incidence of approximately 1:150,000 after epidural blockade (1,2). Thirty percent of patients with spinal subarachnoid hematoma have no risk factors. The incidence in these patients is 1:200,000 after epidural blockade (3). Patients with acute spinal subarachnoid hematoma should undergo laminectomy and decompression within 8 h (1) to minimize neurological injury. We report a case of an ASA I 50-yr-old man, without risk factors for increased bleeding or perioperative thromboprophylaxis, who underwent left herniorrhaphy under epidural anesthesia. His routine preoperative coagulation tests included prothrombin time, activated partial thromboplastin time, and international normalized ratio. The epidural was easily placed in a single attempt at the L3–L4 interspace. The epidural catheter was threaded 4 cm cephalad. No adverse events occurred during the 45 min of surgery. The epidural catheter was removed at the end of the surgery. On the third day after surgery, the patient developed bilateral lumbar pain and paresthesias in the lower limbs. Thinking he had acute sciatica, we treated him with 100 mg a day of ketoprofen, and his symptoms partially improved. Four days later his symptoms returned, accompanied by complete paralysis of the lower limbs. A magnetic resonance imaging (MRI) scan revealed an extensive L2–L4 subarachnoid hematoma (Fig. 1). The patient underwent an emergency laminectomy. Over the next 2 days, the patient’s neurological symptoms resolved slowly. He was discharged 5 days after surgery, with full neurological recovery.Figure 1.: L2–L4 subarachnoid hematoma after epidural puncture.Diagnosis of spinal hematoma was complicated by a lack of risk factors and the late onset of symptoms. The symptoms of acute neuroaxial hematoma often occur within the first 24 h, although onset may vary between 15 min and 7 days. The differential diagnosis of a radicular pain after neuraxial anesthesia includes several clinical syndromes (1,4,5). However, there was no clinical evidence to suggest epidural abscess, bacterial or aseptic meningitis, anterior spinal artery syndrome, traumatic cord lesions, or transitory radicular syndrome (4). The diagnosis of hematoma was made clinically, and confirmed by MRI scan. The usual recommendation is laminectomy within 8 h of onset (2), although there are cases with complete recovery when surgery took place 72 h after the onset of symptoms (6). In our case, the patient had a good outcome, despite the delayed diagnosis and therapy. Esther Agustín, MD Cesar Aldecoa, MD Jesús Rico-Feijoo, MD Jose Ignacio Gómez-Herreras, MD, PhD Department of Anesthesiology and Postoperative Critical Care Rio Hortega University Hospital Valladolid, Spain [email protected]