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Xu W, Guo J, Zhu J, Zhao X, Yasaman I, Chen J, Wang J, Fan S, Fang X. Delayed postoperative spinal epidural hematoma after anterior cervical discectomy and fusion: A case report. Front Surg 2022; 9:1005462. [PMID: 36225220 PMCID: PMC9549240 DOI: 10.3389/fsurg.2022.1005462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative spinal epidural hematoma (POSEH) causes rapid neurological deficits within 24 h following the operation and can be fatal. However, some POSEH symptoms manifest three days after the operation, also known as delayed POSEH (DPOSEH). Little attention has been provided upon DPOSEH owing to its rare incidence, resulting in serious consequences upon occurrence. To date, no cases of delayed POSEH after anterior cervical surgery have been reported.Case presentationWe describe a case of DPOSEH that presented with delayed neurological deficits on the fifth day after anterior cervical discectomy and fusion (ACDF) surgery. Methylprednisolone was administered but showed no efficacy. MR revealed low T1 and strip long T2 signals located behind discs. After emergency surgical decompression, the patient's muscle strength returned to the preoperative state. However, his muscle strength decreased again on the seventh postoperative day, and the patient's family refused further surgery. Nine months after ACDF, the patient died of septic shock and respiratory failure.ConclusionsDPOSEH can occur after three days or more following anterior cervical surgery; hence, monitoring of neurological function is suggested to be extended. Complete evaluation of risk factors, timely recognition, and differentiation of neurological symptoms are required for spine surgery. In the case of DPOSEH, methylprednisolone can be administered reasonably during the transition period. However, if there is no resolution of symptoms, emergency surgery should be performed as soon as possible.
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Affiliation(s)
- Wenbin Xu
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Jiandong Guo
- Department of Orthopaedics, Hangzhou Ninth People's Hospital, Hangzhou, China
| | - Jinjin Zhu
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Xing Zhao
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | | | - Jian Chen
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Jiying Wang
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
| | - Shunwu Fan
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
| | - Xiangqian Fang
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
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Yentis SM, Lucas DN, Brigante L, Collis R, Cowley P, Denning S, Fawcett WJ, Gibson A. Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020. Anaesthesia 2020; 75:913-919. [DOI: 10.1111/anae.14993] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- S. M. Yentis
- Department of Anaesthesia Chelsea and Westminster Hospital London UK
- Imperial College Working Party co‐Chair and Association of Anaesthetists London UK
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Working Party co‐Chair and Obstetric Anaesthetists’ Association London UK
| | - L. Brigante
- Quality and Standards Advisor Royal College of Midwives London UK
| | - R. Collis
- Department of Anaesthesia University Hospital of Wales Obstetric Anaesthetists’ Association Cardiff UK
| | - P. Cowley
- Department of Radiology National Hospital for Neurology and Neurosurgery London UK
| | - S. Denning
- East Midlands School of Anaesthesia Association of Anaesthetists Training Committee UK
| | - W. J. Fawcett
- Royal Surrey County Hospital Association of Anaesthetists Guildford Surrey UK
| | - A. Gibson
- Department of Surgery Royal National Orthopaedic Hospital British Association of Spinal Surgeons Stanmore Middlesex UK
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Treatment of hematomas after anterior cervical spine surgery: A retrospective study of 15 cases. Neurochirurgie 2018; 64:166-170. [PMID: 29735379 DOI: 10.1016/j.neuchi.2017.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 12/21/2017] [Accepted: 12/29/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Postoperative hematoma is a rare and dangerous complication of cervical spine surgery. The aim of this study was to investigate the incidence and related factors of postoperative hematoma, and to report on 15 cases at our institution over a 6-year period. METHODS Fifteen cases of postoperative hematoma were retrospectively identified. We investigated their neurological outcomes, characteristics, and surgical data, and identified risk factors associated with postoperative (PO) hematoma. Patients with hematoma were compared to those with no hematoma, in order to identify risk factors. RESULTS Retropharyngeal hematomas developed in seven cases and epidural hematomas in eight. The total incidence of postoperative hematoma was 1.2%: 0.5% retropharyngeal hematomas and 0.6% spinal epidural hematomas. At time of onset, the severity of paralysis was assessed as grade B in one case, grade C in six cases, and grade D in eight cases. Risk factors for PO hematoma were: (1) presence of ossification of the posterior longitudinal ligament (OPLL) (P<0.001); (2) longer operative duration (P=0.048); (3) greater number of surgical levels (P=0.02); and (4) higher body mass index (BMI; P=0.035). There was no significant difference in modified Japan Orthopedic Association scores between the hematoma group and non-hematoma group (P>0.05). CONCLUSION Precise preoperative preparation and systematic evaluation are central to successful management of PO hematoma after anterior cervical surgery. Risk factors for PO hematoma include multilevel decompression, OPLL, higher BMI, and longer operation time.
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Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
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Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
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Roderick E, Hoyle J, Yentis SM. A national survey of neurological monitoring practice after obstetric regional anaesthesia in the UK. Anaesthesia 2017; 72:755-759. [DOI: 10.1111/anae.13800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | - J. Hoyle
- Whipps Cross Hospital; London UK
| | - S. M. Yentis
- Chelsea and Westminster Hospital; London UK
- Imperial College; London UK
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Update to the management of pediatric acute pancreatitis: highlighting areas in need of research. J Pediatr Gastroenterol Nutr 2014; 58:689-93. [PMID: 24614126 DOI: 10.1097/mpg.0000000000000360] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Acute pancreatitis is an emerging problem in pediatrics, with an incidence that is rising in the last 2 decades. Data regarding the optimal management and physician practice patterns are lacking. We present a literature review and updates on the management of pediatric pancreatitis. Prospective multicenter studies defining optimal management of pediatric pancreatitis are needed to guide care and improve outcomes for this patient population.
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Keys to minimizing the risk of spinal cord trauma during a lumbar approach to thoracic epidural. Can J Anaesth 2014; 61:289-94. [PMID: 24477465 DOI: 10.1007/s12630-014-0120-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022] Open
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Pancreatic nociception--revisiting the physiology and pathophysiology. Pancreatology 2012; 12:104-12. [PMID: 22487519 DOI: 10.1016/j.pan.2012.02.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/23/2012] [Accepted: 02/19/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pain management of many pancreatic diseases remains a major clinical concern. This problem reflects our poor understanding of pain signaling from the pancreas. OBJECTIVES This review provides an overview of our current knowledge, with emphasis on current pain management strategies and recent experimental findings. METHODS A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring pain and its management in disease states such as acute pancreatitis (AP), chronic pancreatitis (CP) and pancreatic cancer (PC). RESULTS Over the last decade, numerous molecular mediators such as nerve growth factor and the transient receptor potential (TRP) cation channel family have been implicated in afferent nerve signaling. More recent animal studies have indicated the location of the receptive fields for the afferent nerves in the pancreas and shown that these are activated by agents including cholecystokinin octapeptide, 5-hydroxytryptamine and bradykinin. Studies with PC specimens have shown that neuro-immune interactions occur and numerous agents including TRP cation channel V1, artemin and fractalkine have been implicated. Experimental studies in the clinical setting have demonstrated impairment of inhibitory pain modulation from supraspinal structures and implicated neuropathic pain mechanisms. CONCLUSIONS Our knowledge in this area remains incomplete. Characterization of the mediators and receptors/ion channels on the sensory nerve terminals are required in order to facilitate the development of new pharmaceutical treatments for AP and CP.
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Acute Epidural Spinal Hemorrhage from Vasculitis: Resolution with Immunosuppression. Neurocrit Care 2012; 16:311-5. [DOI: 10.1007/s12028-011-9667-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Carragee EJ, Golish SR, Scuderi GJ. A case of late epidural hematoma in a patient on clopidogrel therapy postoperatively: when is it safe to resume antiplatelet agents? Spine J 2011; 11:e1-4. [PMID: 21095164 DOI: 10.1016/j.spinee.2010.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/09/2010] [Accepted: 10/19/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of antiplatelet agents after coronary artery stent placement is currently recommended to prevent coronary stent obstruction. These patients may have concurrent disabling spinal stenosis and require spinal decompression. Resuming antiplatelet agents as soon as possible after spinal surgery is recommended. PURPOSE To describe a unique case of late postoperative epidural hematoma occurring with the use of clopidogrel. STUDY DESIGN A case report and review of the literature. METHODS The hospital chart, history, physical examination, and imaging of a single patient were reviewed. RESULTS A 59-year-old man underwent spinal decompression and fusion for neurogenic claudication with lumbar spinal stenosis and spondylolisthesis while managed on clopidogrel for prevention of thrombosis after cardiac stent placement. He developed a symptomatic epidural hematoma 12 days postoperatively, well outside the usual time frame for this complication. The patient was closely monitored, and lumbar radiculopathy resolved over the ensuing days. CONCLUSION After spinal surgery and resumption of antiplatelet therapy, the physician needs to maintain vigilance in observing patients for late postoperative complications such as epidural hematoma, which could have catastrophic consequences if not recognized in a timely manner.
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Affiliation(s)
- Eugene J Carragee
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA 94063-6342, USA
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Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010; 54:16-41. [PMID: 19839941 DOI: 10.1111/j.1399-6576.2009.02089.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.
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Affiliation(s)
- H Breivik
- Section for Anaesthesiology and Intensive Care Medicine, University of Oslo, Rikshospitalet, Oslo, Norway.
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Sarikaya-Seiwert S, Gierga K, Wessalowski R, Steiger HJ, Hänggi D. Solitary spinal epidural cavernous angiomas in children presenting with acute neurological symptoms caused by hemorrhage. J Neurosurg Pediatr 2010; 5:89-93. [PMID: 20043742 DOI: 10.3171/2009.7.peds09203] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal solitary epidural cavernous angiomas are rare benign vascular malformations, which occur even less frequently in children than in adults. It is uncommon to find such lesions without adjacent vertebral involvement. Occasionally, these lesions can lead to neurological symptoms through growth or due to intralesional hemorrhage. In this report the authors describe 2 children presenting with acute symptoms and neurological deficits caused by hemorrhage within solitary spinal epidural cavernous angiomas. A 13-year-old girl and a 9-year-old girl, previously healthy, were admitted to the authors' department due to acute radicular pain and neurological deficits. In both cases MR imaging revealed a solitary epidural mass with signs of bleeding and compression of the spinal cord. Complete resection of the lesion via a dorsal approach was performed in both patients. The histological examination of the lesions revealed the characteristic structures of a cavernous angioma with hemosiderin deposits and acute hemorrhage. Both patients recovered fully after surgical removal of the lesions. Review of the literature confirmed that spinal epidural cavernous angiomas are extremely rare in the pediatric patient population, described currently in only 2 instances, but without acute hemorrhage. These cases suggest that epidural cavernous angiomas also have to be considered in the pediatric patient population in the differential diagnosis of intraspinal lesions with acute or progressive neurological symptoms. Microsurgical resection of these cavernous malformations is an effective and curative treatment option.
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Caruso G, Galarza M, Borghesi I, Pozzati E, Vitale M. Acute presentation of spinal epidural cavernous angiomas: case report. Neurosurgery 2007; 60:E575-6; discussion E576. [PMID: 17327768 DOI: 10.1227/01.neu.0000255345.48829.0b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Spinal extramedullary hematomas stemming from cavernous angiomas in the epidural compartment are rare. It is more common for spinal epidural cavernous angiomas to present with slow and progressive myelopathy or radiculopathy. They seldom present with clinical evidence of acute spinal cord or nerve root compression. CLINICAL PRESENTATION Three consecutive cases of acute spinal cavernous angiomas with overt neurological deficits were presented. These presentations included acute onset of neck pain and tetraparesis, bilateral lower extremity pain and paraparesis, and acute sciatic pain with plantar flexor weakness. The lesions were located in the cervical, thoracic, and sacral spine, respectively. The cases included either abrupt lesion enlargement secondary to a pure intralesional hemorrhage or a cavernous hemorrhage that invaded the epidural space. INTERVENTION All patients were treated with either laminotomy or complete resection of the hematoma and cavernoma within 12 hours after admission. CONCLUSION Spontaneous spinal epidural hematomas presented with significant pain and acute spinal cord and nerve root compression may represent the manifestation of a cavernous angioma. Appropriate interpretation of preoperative imaging studies may prevent delay in proper management, especially for patients in whom nerve root deficit is the only clinical expression.
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Affiliation(s)
- Giuseppe Caruso
- Division of Neurosurgery, Villa Maria Cecilia Hospital, Cotignola, Italy
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Zhang H, He M, Mao B. Thoracic spine extradural arteriovenous fistula. ACTA ACUST UNITED AC 2006; 66 Suppl 1:S18-23; discussion S23-4. [PMID: 16904990 DOI: 10.1016/j.surneu.2006.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 05/19/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Spinal extradural arteriovenous fistula is a rare, disabling, but potentially treatable disease. Only 27 cases have been reported so far in the past 40 years. CASE DESCRIPTION An 18-year-old adolescent girl developed repeated back pain and mild paraplegia after a training course. Magnetic resonance imaging revealed a vessel-like lesion at the spinal extradural space, compressing the spinal medulla at the T5 level. Angiography disclosed a focal fistula fed by branches of the intercostal artery. The vascular mass was surgically removed and confirmed pathologically. CONCLUSION Spinal extradural arteriovenous fistulas have an arterial supply that originates outside the spinal dura, with venous draining into the spinal extradural venous plexus. They may lead to myelopathy, radiculopathy, or spontaneous extradural hematoma, due to dilated vein compression, blood stealing, or spinal venous hypertension. Extradural hematoma needs emergency laminectomy and clot evacuation. And extradural arteriovenous fistulas should be treated actively by embolization, surgical resection, or both. Appropriate treatment will stabilize the patient or result in neurological improvement.
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Affiliation(s)
- Heng Zhang
- Department of Neurosurgery, West China Hospital, West China Clinical Medical School, Sichuan University, Chengdu, Sichuan Province 610041, PR China.
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Wynn MM, Mittnacht A, Norris E. Con: Surgery Should Not Proceed When a Bloody Tap Occurs During Spinal Drain Placement for Elective Thoracoabdominal Aortic Surgery. J Cardiothorac Vasc Anesth 2006; 20:273-5. [PMID: 16616676 DOI: 10.1053/j.jvca.2005.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Indexed: 11/11/2022]
MESH Headings
- Aortic Aneurysm, Abdominal/complications
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/complications
- Aortic Aneurysm, Thoracic/surgery
- Contraindications
- Elective Surgical Procedures
- Hematoma, Epidural, Spinal/cerebrospinal fluid
- Hematoma, Epidural, Spinal/diagnosis
- Hematoma, Subdural, Spinal/cerebrospinal fluid
- Hematoma, Subdural, Spinal/diagnosis
- Humans
- Risk Factors
- Spinal Puncture
- Vascular Surgical Procedures
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Affiliation(s)
- Martha M Wynn
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. ACTA ACUST UNITED AC 2005; 87:1248-52. [PMID: 16129751 DOI: 10.1302/0301-620x.87b9.16518] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.
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Affiliation(s)
- J N Awad
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, A672, Baltimore, Maryland 21224, USA
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Endo H, Takahashi T, Shimizu H, Tominaga T. Thoracic Intradural Arachnoid Cyst Associated With Surgical Removal of Epidural Hematoma-Case Report-. Neurol Med Chir (Tokyo) 2004; 44:607-10. [PMID: 15686183 DOI: 10.2176/nmc.44.607] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 54-year-old woman presented with a very rare association of spinal intradural arachnoid cyst and spinal epidural hematoma manifesting as paraparesis subsequent to severe back pain. Magnetic resonance (MR) imaging disclosed a ventral epidural hematoma extending from the T-4 to T-6 levels and compressing the spinal cord ventrally. Emergent surgical evacuation of the epidural hematoma was carried out 22 hours after the onset. MR imaging obtained 2 days after surgery showed enlargement of the dorsal subarachnoid space at the T-3 to T-8 levels. The patient could walk independently within 6 months after discharge, but paraparesis recurred 3 years after surgery. MR imaging showed formation of an intradural arachnoid cyst, which compressed the spinal cord dorsally. She underwent arachnoid cystectomy, and recovered ambulation postoperatively. This case of intradural arachnoid cyst of the thoracic spine which appeared after surgical removal of an epidural hematoma at the same spinal level indicates some association between the epidural hematoma and the arachnoid cyst.
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Affiliation(s)
- Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
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Akutsu H, Sugita K, Sonobe M, Matsumura A. A case of nontraumatic spinal epidural hematoma caused by extradural varix: consideration of etiology. Spine J 2003; 3:534-8. [PMID: 14609701 DOI: 10.1016/s1529-9430(03)00153-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Many cases of nontraumatic spinal epidural hematoma (SEH) have been reported, although the etiology of SEH remains unclear. PURPOSE Our purpose was to report a rare case of nontraumatic acute SEH caused by extradural varices and to discuss the etiology of this entity. STUDY DESIGN/SETTING Case report. PATIENT SAMPLE A 27-year-old man. OUTCOME MEASURES Resolution of the patient's paraplegia, and pathological examination of the epidural vein of the patient and three other patients with cervical spondylosis. METHODS Not applicable. RESULTS The patient recovered from paresis of both hands, although paraplegia remains complete. Pathological examination of the patient revealed abnormal veins that had thickened walls, varying caliber, and internal elastic lamina. In two of the three patients with cervical spondylosis, abnormally dilated veins resembling those in the SEH patient were observed. CONCLUSIONS We describe a rare case of SEH caused by extradural varices. It is speculated that spinal epidural veins can possibly develop an abnormal structure and fragility as seen in the present case and in spondylotic cases.
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Affiliation(s)
- Hiroyoshi Akutsu
- Department of Neurosurgery, Mito National Hospital, Ibaraki, Japan.
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Pastor MC, Sánchez MJ, Casas MA, Mateu J, Bataller ML. Thoracic epidural analgesia in coronary artery bypass graft surgery: seven years' experience. J Cardiothorac Vasc Anesth 2003; 17:154-9. [PMID: 12698394 DOI: 10.1053/jcan.2003.39] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate the risk of neurologic complications caused by an epidural hematoma in a series of patients who had coronary artery bypass graft surgery with cardiopulmonary bypass under combined general and thoracic epidural anesthesia (TEA). DESIGN Prospective observational study. SETTING General hospital associated with a university. PARTICIPANTS Seven hundred fourteen patients who had coronary artery bypass grafting surgery over a 7-year period. INTERVENTIONS An epidural catheter was inserted at T(1)-T(3) as soon as the patient was in the operating room and local anesthetic was administered as a bolus and then as a continuous infusion throughout the operation and postoperatively. A set of safety guidelines was routinely followed. A protocol for postoperative neurologic evaluation was used to rule out any signs of spinal compression. MEASUREMENTS AND MAIN RESULTS Preoperatively, a battery of coagulation tests was systematically performed including APTT, platelet count, and prothrombin time. Antiplatelet drugs (aspirin) were stopped at least 7 days before surgery. No patient required parenteral opiates postoperatively. Seventy-five percent of the patients were extubated in the operating room. No clinical epidural hematomas were detected. CONCLUSION In this study, some of the benefits previously reported during cardiac surgery under TEA, such as excellent analgesia and early extubation, were confirmed. In addition, the series adds further evidence that adherence to a set of standard safety measures, in this setting, averts the occurrence of symptomatic epidural hematomas.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia, Epidural/adverse effects
- Anesthesia, Epidural
- Anesthesia, General
- Cardiopulmonary Bypass
- Coronary Artery Bypass
- Female
- Hematoma, Epidural, Cranial/blood
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Epidural, Cranial/prevention & control
- Humans
- Male
- Nervous System Diseases/etiology
- Nervous System Diseases/prevention & control
- Postoperative Complications/epidemiology
- Prospective Studies
- Risk Factors
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Taguchi Y, Matsuzawa M, Ye JM, Uzura M, Watanabe H, Hayakawa M. Posttraumatic cervical epidural hematoma associated with congenital absence of a cervical spine pedicle: case report and literature review. THE JOURNAL OF TRAUMA 2001; 51:579-82. [PMID: 11535915 DOI: 10.1097/00005373-200109000-00030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Y Taguchi
- Division of Neurosurgery, Department of Radiology, St. Marianna University Yokohama City Seibu Hospital, 1197-1 Yasashi-cho, Asahi-ku, Yokohama, Kanagawa, Japan 241-0811
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Hui AC, Wong HT, Lam JM. Spinal epidural haematoma misdiagnosed as meningitis. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2001; 62:571. [PMID: 11584621 DOI: 10.12968/hosp.2001.62.9.1651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 32-year-old man developed sudden onset neck pain while at work. There was no headache, fever and no history of head or neck injury. He had been in good health. He continued to work and went home after seeing his doctor, who diagnosed muscle strain. Four days later the pain persisted and he was admitted to hospital. Examination revealed marked neck stiffness, generalized hyperreflexia but with preserved power and a fever of 38°C. Urgent computed tomography of the brain was normal. The blood white cell count was normal. CSF analysis revealed red blood cells and some white blood cells, a blood-stained high protein count of 7 g/litre and a low glucose of 0.7 mmol/litre. Simultaneous blood sugar concentration was 6.7 mmol/litre.
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Affiliation(s)
- A C Hui
- Department of Medicine, Prince of Wales Hospital, Shatin, Hong Kong
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When You Suspect Epidural Hematoma. Am J Nurs 2000. [DOI: 10.1097/00000446-200009000-00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Takahashi K, Koiwa F, Tayama H, Satomi A, Akizawa T, Ideura T. A case of acute spontaneous epidural haematoma in a chronic renal failure patient undergoing haemodialysis: successful outcome with surgical management. Nephrol Dial Transplant 1999; 14:2499-501. [PMID: 10528685 DOI: 10.1093/ndt/14.10.2499] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- K Takahashi
- Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
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Van Schaeybroeck P, Van Calenbergh F, Van De Werf F, Demaerel P, Goffin J, Plets C. Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases. Clin Neurol Neurosurg 1998; 100:283-7. [PMID: 9879854 DOI: 10.1016/s0303-8467(98)00044-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Three patients with a spontaneous spinal epidural hematoma are presented, one of which is exceptional because it could be attributed to thrombolysis with alteplase. The other two were correlated with oral anticoagulant therapy. Our second case suggests that Morbus Kahler may be an underlying pathology in spinal extradural hematoma. In the third patient neither an obvious 'locus minoris resistentiae' nor a pathological coagulation test could be held responsible for the spontaneous bleeding. All three patients underwent laminectomy and evacuation of the hematoma. Although two of our cases are examples of complete recuperation after late operative intervention, early surgery is preferable. Permanent clinical attention together with a low threshold to perform magnetic resonance imaging (MRI) leads to a quicker diagnosis of spinal epidural hematoma. We show that administration of gadolinium may facilitate correct preoperative localization of the hematoma because there may be contrast enhancement of the hematoma. Finally, the postoperative policy concerning thromboembolic prophylaxis is discussed.
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Hayem G, Deutsch E, Roux S, Palazzo E, Grossin M, Meyer O. Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report. Spine (Phila Pa 1976) 1998; 23:2432-5. [PMID: 9836358 DOI: 10.1097/00007632-199811150-00015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae. OBJECTIVES To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions. SUMMARY OF BACKGROUND DATA There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases. METHODS A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression. RESULTS The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy. CONCLUSIONS This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.
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Affiliation(s)
- G Hayem
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France.
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Miyagi Y, Miyazono M, Kamikaseda K. Spinal epidural vascular malformation presenting in association with a spontaneously resolved acute epidural hematoma. Case report. J Neurosurg 1998; 88:909-11. [PMID: 9576263 DOI: 10.3171/jns.1998.88.5.0909] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A 16-year-old boy developed acute neck pain and severe quadriparesis after mild rotatory movement of his neck. Magnetic resonance imaging revealed a cervical epidural hematoma that resolved spontaneously within a few days. Vertebral angiography demonstrated a small vascular malformation in the upper cervical epidural space. The vascular mass on the dural surface was totally resected and confirmed to be an arteriovenous malformation. This case represents the importance of including routine angiography in designing therapeutic strategy for cases of spinal epidural hematoma with spontaneous resolution.
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Affiliation(s)
- Y Miyagi
- Department of Neurosurgery, Kaizuka Hospital, Fukuoka, Japan
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Schmitz A, Wallny T, Sommer T, Brackmann H, Schulze-Bertelsbeck D, Effenberger W, Kowalski S. Spinal epidural haematoma in haemophilia A. Haemophilia 1998; 4:51-5. [PMID: 9873866 DOI: 10.1046/j.1365-2516.1998.00133.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We report on a 27-year-old male Caucasian with severe haemophilia A who presented with acute onset of neck pain with cervical nerve root irritation, due to a spinal epidural haematoma. His past medical history revealed carrying of a moderate weight as a possible traumatic mechanism. Under immediate factor VIII replacement therapy complete remission of the symptoms was achieved within several days. The diagnosis of spinal epidural haematoma and complete resorption was revealed by initial and follow-up magnetic resonance imaging studies of the cervical spine. Having reviewed the literature on spinal epidural haematoma, we present an overview of the treatment and outcome as regards haemophilia.
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Affiliation(s)
- A Schmitz
- University of Bonn, Department of Orthopaedics, Germany
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