Paraplegia after epidural anesthesia in a patient with peripheral vascular disease: case report and review of the literature with a description of an original technique for hematoma evacuation

Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors

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.

[Subdural hematoma complicating epidural anesthesia in vascular surgery]

L'hématome péri médullaire est une complication rare, parfois invalidante de l'anesthésie péridurale. Il survient au décours d'une ponction difficile ou traumatique ou après une mauvaise gestion des anticoagulants. Son diagnostic est difficile parfois retardé. L'imagerie par résonance magnétique reste l'examen de choix. Le traitement est essentiellement chirurgical. Le pronostic dépend de l'importance de l'hématome et des lésions sous jacentes. Nous rapportons l'observation d'un hématome sous dural dorsal, compliquant une anesthésie péridurale en postopératoire d'un pontage aorto-bi fémoral, pour anévrysme de l'aorte abdominal sous rénale.

Results of preemptive epidural administration of morphine with or without bupivacaine in dogs and cats undergoing surgery: 265 cases (1997-1999)

OBJECTIVE

To determine prevalence of adverse effects associated with epidural administration of morphine with or without bupivacaine in dogs and cats undergoing surgery and evaluate effects of epidural administration of morphine on postoperative pain severity.

DESIGN

Retrospective study.

ANIMALS

242 dogs and 23 cats.

PROCEDURE

Morphine with or without bupivacaine was administered prior to surgery with a Tuohy needle, spinal needle, or epidural catheter. In 18 dogs that underwent surgery twice, results of preemptive epidural administration of morphine with or without bupivacaine were compared with results of systemic administration of oxymorphone and ketoprofen.

RESULTS

The delivered fraction of isoflurane was significantly lower in animals given morphine and bupivacaine than in animals given morphine alone. Analgesia was of significantly longer duration in dogs given morphine and bupivacaine than in dogs given morphine alone. During anesthesia, mild respiratory and cardiovascular depression was reported. Seven dogs and 2 cats had urine retention, and 2 dogs developed pruritus. Six dogs vomited when a second dose of morphine was given epidurally the day after surgery. Eight of 72 dogs had delayed hair growth. In 18 dogs that underwent surgery twice, the delivered fraction of isoflurane was significantly lower and the duration of analgesia was significantly longer when morphine with or without bupivacaine was given epidurally than when oxymorphone and ketoprofen were given.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that preemptive epidural administration of morphine with or without bupivacaine is a safe and effective method of inducing long-lasting analgesia in dogs and cats and is superior to standard management of postoperative pain with repeated injection of oxymorphone and ketoprofen.