Spinal haematoma following epidural analgesia

Interlaminar versus transforaminal epidural steroid injections: a review of efficacy and safety

Spine intervention is an important treatment option for the management of spinal pain, and the numbers of the most representative epidural steroid injection (ESI) procedures performed are expected to increase significantly in the future along with increased life expectancy and the increasing prevalence of spinal disorders. Therefore, it is important to understand the efficacy of ESIs according to each spinal disorder they are administered to treat, and one must be familiar with the possible complications. In fact, although numerous ESI-related articles have been published, there is still considerable controversy regarding the efficacy of ESI procedures. Furthermore, due to the rarity of serious complications, most instances have been recorded in the form of case reports. In this article, we aimed to review the indications of cervical and lumbar ESIs and to compare interlaminar ESI (ILESI) and transforaminal ESI (TFESI) techniques in terms of analgesic efficacy, possible complications, and safety profiles. This article includes opinions based on the authors' experience with ESI indications and efficacy, and presents practical tips for coping with specific situations related to each complication. By combining the dedicated anatomical understanding of radiologists with image-guided interventions, ESI is expected to stand out in the rapidly expanding field of spine intervention.

Unilateral bi-portal endoscopy for unilateral L5 nerve injury due to post-traumatic epidural hematoma at T12/L1 level: A case report and literature review

INTRODUCTION AND IMPORTANCE

Spinal epidural hematoma (SEH) is an uncommon condition that can result in severe neurological problems and needs to be treated as soon as possible. The incidence of traumatic SEH is 0.5 %-1.7 %, but increases to 9 % in patients with rheumatic diseases. Surgical treatment options include open surgery and minimally invasive surgery. We reported a post-traumatic SEH at T12/L1 level combined with L5 nerve injury and treated by UBE technique. To our knowledge, there was no reported cases like this.

CASE PRESENTATION

A 38-year-old man with left leg weakness and severe back pain after fell down while cycling. Physical examination suggested left hip abduction was 2/5 strength, left dorsiflexion of hallux dorsal extension was 0/5 strength and the left ankle dorsiflexion was 2/5 strength. Magnetic resonance images (MRI) of lumbar spine showed a two-leveled hematoma extending from T12 to L1. After 1 year of surgery, the patient's symptoms had largely disappeared and he was able to perform daily activities independently.

CLINICAL DISCUSSION

An epidural hematoma at the L1 level is can cause symptoms of the L5 nerve root alone, which may be due to anatomical reasons. Complete removal of the epidural hematoma is necessary to restore the function of the nerve. We report a case of successful removal of an epidural hematoma using the UBE technique with good postoperative results.

CONCLUSIONS

The single nerve injury can occur with a thoracolumbar segmental hematoma, and UBE technology could be used to remove epidural hematoma.

Report of cerebral vasospasm as a complication of intracranial subarachnoid hemorrhage following traumatic lumbar puncture

Background:

This case report is the first documented and illustrated case of the identification and treatment of intracranial vasospasm as a sequalae of traumatic lumbar puncture (LP). LP is a routine procedure performed for both diagnostic and therapeutic purposes. Although rare, this procedure has risks and complications that should be considered before performing.

Case Description:

A 58-year-old male was found to have intracranial subarachnoid hemorrhage (SAH) 2 days after a traumatic LP which occurred in the setting of subtherapeutic international normalized ratio. During his hospitalization, the patient developed both clinical and radiographic signs of vasospasm. He was taken for angiography, which demonstrated significant vasospasm of bilateral middle cerebral arteries and bilateral anterior cerebral arteries. All vasospasms resolved and the patient improved clinically after intra-arterial spasmolytic therapy.

Conclusion:

LP is a routine procedure with complications that are often overlooked. The authors describe intracranial vasospasm from traumatic LP before correction of patient’s coagulopathy. Cases with similar hemorrhage occurring in the spine resulting in non-aneurysmal SAH and vasospasm were reviewed.

Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures

Spontaneous and chronic epidural hematoma (SSEH) in the lumbar spine is rare, and idiopathic and chronic SSEH in the lumbar spine is extremely rare disease. Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. Definitive guidelines for management of this condition are not clear and surgical total evacuation was performed in most of the cases. Some authors reported the epidural bleeding originates in the rupture of Batson’s plexus due to a rise in intra-abdominal pressure, but the mechanism is not clearly clarified. We report a surgical case of idiopathic and chronic SSEH. A 61-year-old woman suffered a sudden onset of severe lumbar pain during sleep. She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5. This patient underwent the partial evacuation of the hematoma with partial hemilaminectomy on left at L2/3, resulting in immediate pain relief and resolution of symptoms and almost absorption of the hematoma within 1 week of the procedure. We presented this rare case and reviewed idiopathic and chronic epidural hematoma in the lumbar spine.

Epidural hematoma after total hip arthroplasty in ankylosing spondylitis patient: A case report and review of the literature

RATIONALE

Ankylosing spondylitis (AS) can affect the hip joint, causing deformity and disability. Total hip arthroplasty can obviously relieve the pain of the hip joint, and reconstruct the function of hip joint. Epidural anesthesia in this patient population has high risk of epidural hematoma, but the reason is unclear.

PATIENT CONCERNS

A 44-year-old man diagnosed with AS underwent total hip arthroplasty.

DIAGNOSES

Six days after operation, he was diagnosed epidural hematoma.

INTERVENTIONS

Laminectomy and decompression surgery was performed.

OUTCOMES

At the last follow-up, he recovered the feeling and function of lower limbs. A literature review was undertaken to understand the incidence and risk factors. The incidence of spinal hematoma in this population is high and only probable risk factors are reported without further research.

LESSONS

Based on our review and the illustration of this case, AS patients have both lumbar and hip bony fusion. The exact bone canal caused by the lumbar puncture needle may play an important role in epidural hematoma. General anesthesia may be a better choice for this special patient cohort.

Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature

Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.

Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines

Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

Postthoracotomy paravertebral analgesia: will it replace epidural analgesia?

Thoracotomy is associated with significant acute postoperative pain and a high incidence of development of chronic pain. Thoracic epidural analgesia has long been standard treatment for postthoracotomy pain, but recently there has been increased interest in alternative regional techniques, particularly paravertebral analgesia. This article compares the analgesic efficacy, side effects, complications of, and contraindications for thoracic epidural and paravertebral analgesia techniques and discusses their effects on the development of chronic postthoracotomy pain. This information will allow a more considered choice of analgesic technique after thoracotomy.

Spinal epidural hematoma after removal of an epidural catheter: case report and review of the literature

We report a case of spinal epidural hematoma after removal of an epidural catheter. The patient had no background of anticoagulant therapy or coagulopathy; sudden severe back pain occurred immediately after removal of the catheter. The chance of this occurring is estimated to be between 1:150,000 and 1:190,000. We studied 40 previous reports from 1952 to 2000, and we also investigated anticoagulant therapy and pathologic states, puncture difficulties and bleeding at the point of insertion, and its onset. In 23 cases (57.5%), anticoagulant therapy had been performed, and in 5 cases (12.5%), coagulopathy or liver dysfunction had been recognized. In 20 cases (50%), the initial symptoms were recognized within 24 hours after removal of the epidural catheter. Although spinal epidural hematoma is a very rare condition, it is a serious complication of continuous epidural anesthesia.

Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections

OBJECTIVES

To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections.

DESIGN

A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed.

RESULTS

A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137).

CONCLUSIONS

No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

Epidural Hematoma Unrelated to Combined Spinal-Epidural Anesthesia in a Patient with Ankylosing Spondylitis Receiving Aspirin After Total Hip Replacement

Although rare, major complications after spinal and epidural anesthesia do occur. The safety of spinal and epidural anesthesia has been well established. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinal-epidural anesthetic. Most epidural hematomas are spontaneous and idiopathic.

[Spondylodiscitis after perioperative peridural catheter]

Peridural anaesthesia is used to avoid operative, postoperative and chronic pain, especially in surgery, gynecology and urology. Complications have rarely been described but can entail serious local and systemic sequelae. Three cases with spondylitis and spondylodiscitis after peridural anaesthesia are presented. The failure to recognize the peridural catheter as the cause of vertebral pain led to therapeutic delay in two cases. The result of antimicrobial therapy and in two cases radical surgical treatment was complete recovery. The occurrence of spondylodiscitis after the use of peridural catheters is often a late manifestation of disseminated pathogens. The insidious progression of infection and non-specificity of clinical symptoms may lead to diagnostic delay. Awareness of the possibility of even delayed complications after the use of peridural anaesthesia is important.

Epidural abscess after epidural catheter for pain release during pancreatitis

BACKGROUND

Despite knowledge about compromised host defence in the course of diabetes mellitus and pancreatitis, epidural analgesia (EA) is recommended for pain management during pancreatitis.

CASE REPORT

We present the case of a diabetic patient with pancreatitis who developed an epidural abscess after 3 days with an epidural catheter. Natural killer and T-helper cell counts were distinctively reduced in the absence of HIV serology. Furthermore, a synthesis failure of the liver was observed and evidenced by low cholinesterase, low whole protein fraction and low antithrombin III in the peripheral blood.

CONCLUSION

We suggest that the combination of pancreatitis, diabetes and compromised immunity might be a contraindication to epidural analgesia.

Neurologic complications in the intensive care unit

Neurologic complications resulting from critical illness and intensive care unit therapies are common, but frequently unrecognized because these patients are often intubated, sedated, and, occasionally, receiving neuromuscular blocking agents. Neurologic complications are associated with an increased intensive care unit mortality. This article discusses central nervous system complications that are secondary to critical illness or to therapeutic interventions in the critically ill patient.

Epidural anesthesia in cardiac surgery: is there an increased risk?

OBJECTIVE

To assess the risk of hemorrhagic complications associated with epidural anesthesia in patients undergoing coronary artery bypass grafting.

DESIGN

A prospective study.

SETTING

A cardiac surgical center associated with a university.

PARTICIPANTS

Five hundred fifty-eight consecutive patients scheduled for coronary artery bypass surgery.

INTERVENTIONS

A Tuohy 18G epidural catheter was inserted the day before surgery in all patients.

MEASUREMENTS AND MAIN RESULTS

Preoperative coagulation tests, such as platelet count and prothrombin time, were performed. No patient was on oral anticoagulation therapy or had coagulation disorders. Four hundred three (72%) patients were on antiplatelet therapy, which was terminated at least 1 week before surgery. The epidural catheter was left in situ for up to 5 days. All patients were observed daily for signs of spinal cord compromise, such as radicular back pain or progressive sensory or motor deficits. There were no documented spinal hematomas.

CONCLUSION

By following certain guidelines, the risk for the development of epidural hematoma is not increased in patients undergoing epidural anesthesia during cardiac surgery.

Epidural anaesthesia and spinal haematoma

PURPOSE

Haematoma formation in the spinal canal due to epidural anaesthesia is a very rare but serious complication. This paper presents a comprehensive review of case reports.

SOURCE

Sampling of case reports over a 10 yr period, medline-research (1966-1995) and cross-check with former reviews.

FINDINGS

Fifty-one confirmed spinal haematomas associated with epidural anaesthesia were found. Most were related to the insertion of a catheter, a procedure that was graded as difficult or traumatic in 21 patients. Other risk factors were: fibrinolytic therapy (n = 2), previously unknown spinal pathology (n = 2), low molecular weight heparin (n = 2), aspirin or other NSAID (n = 3), epidural catheter inserted during general anaesthesia (n = 3), thrombocytopenia (n = 5), ankylosing spondylitis (n = 5), preexisting coagulopathy (n = 14), and intravenous heparin therapy (n = 18).

CONCLUSION

Coagulopathies or anticoagulant therapy (e.g., full heparinization) were the predominant risk factors, where-as low-dose heparin thromboprophylaxis or NSAID treatment was rarely associated with spinal bleeding complications. Ankylosing spondylitis was identified as a new, previously unreported risk factor. Analysis of reported clinical practice suggests an incidence of haematoma of 1:190,000 epidurals.

Thromboprophylaxis, coagulation disorders, and regional anaesthesia

The surgery and trauma-induced modulation of the coagulation system includes a considerable risk of perioperative thromboembolic complications unless effective thromboprophylactic treatment is given. In the present survey the patient at risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is characterized and the documented efficacy of different currently used thromboprophylactic regimens is summarized. Systemic thromboprophylactic treatment may include a risk of an increased bleeding tendency which may lead to haemorrhagic complications. In patients with a coagulation abnormality or in patients receiving anticoagulants for perioperative thromboprophylaxis there is a fear among anaesthesiologists that the use of regional anaesthesia (spinal or epidural) may be associated with spinal haemorrhagic complications, i.e. with spinal haematoma formation leading to compression of the spinal cord and severe neurologic sequelae. Present aspects on the risk of spinal haematoma formation at the combined use of pharmacological thromboprophylactic regimens and spinal or epidural anaesthesia/ analgesia are therefore summarized. Pregnancy is associated with changes in the haemostatic system, which in the preeclamptic or eclamptic patient may be rather pronounced and constitute a clinical problem since regional anaesthetic techniques are often preferred for obstetric anaesthesia/analgesia. The specific problems to be considered prior to the choice of regional anaesthesia/analgesia for a parturient with a suspected coagulation disorder are therefore commented on in more detail. Finally, recommendations are given for safe spinal and epidural analgesic and anaesthetic routines in patients with potential haemostatic disturbances due to thromboprophylactic treatment with anticoagulants or bleeding disorders.

Neurological complications after anaesthesia. A follow-up of 18,000 spinal and epidural anaesthetics performed over three years

17 733 consecutive central blocks (8501 spinal and 9232 epidural anaesthetics) performed during a three-year period were analyzed for alleged complications. Neurological complications related to anaesthesia were reported in 17 cases of which 13 patients had persisting lesions after three spinal and ten epidural blocks. In two patients given spinal anaesthesia, the technique was inadequate. In seven epidural blocks, the connection between neurological lesion and the anaesthetic technique could be argued. In five of these cases, polyneuropathy or nonspecific neurological symptoms were present. Three complications after epidural blocks were paraplegias caused by spinal haematomas in patients with deranged haemostatic capacity.

Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia

One thousand orthopedic procedures in 924 patients given spinal or epidural anesthesia were prospectively studied to determine the risk of hemorrhagic complications associated with regional anesthesia. A history of excessive bruising or bleeding was elicited in 115 (12%) patients. Preoperative antiplatelet medications were taken by 386 (39%) patients. Aspirin was the most frequently reported antiplatelet drug and was taken by 193 patients. Subcutaneous heparin was administered to 22 patients before surgery on the operative day. One patient of 774 tested had a preoperative platelet count less than 100,000/mm3. In addition, 26 of 171 preoperative prothrombin times and 10 of 115 preoperative activated partial thromboplastin times were longer than normal. Only 31 preoperative bleeding times were performed; five were prolonged. There were no documented spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement (minor hemorrhagic complication) in 223 (22%) patients, including 73 patients with frank blood in the needle or catheter. Preoperative antiplatelet therapy did not increase the incidence of minor hemorrhagic complications. However, female gender, increased age, a history of excessive bruising/bleeding, surgery to the hip, continuous catheter anesthetic technique, large needle gauge, multiple needle passes, and moderate or difficult needle placement were all significant risk factors. The lack of correlation between antiplatelet medications and bloody needle or catheter placement (producing clinically insignificant collections of blood in the spinal canal or epidural space) is strong evidence that preoperative antiplatelet therapy is not a significant risk factor for the development of neurologic dysfunction from spinal hematoma in patients who undergo spinal or epidural anesthesia while receiving these medications.

Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients

In a prospective study, the complications of 1071 patients scheduled for thoracic epidural catheterization for postoperative analgesia (TEA) were studied. All catheters were inserted preoperatively between segment Th 2/3 and Th 11/12 under local anesthesia. Balanced anesthesia with endotracheal intubation and TEA were combined. Postoperatively 389 patients (36.9%) were monitored on a normal surgical ward. Buprenorphine, 0.15 to 0.3 mg, and if needed bupivacaine 0.375% 3-5 ml h-1 were given epidurally. Primary perforation of the dura occurred in 13 patients (1.23%). Radicular pain syndromes were observed in six patients (0.56%). In one patient (0.09%) respiratory depression was seen in close connection with the epidural administration of 0.3 mg buprenorphine. Although 116 patients (10.83%) showed one abnormal clotting parameter but no clinical signs of hemorrhage, there was no complication related to this group. No persisting neurological sequelae caused by the thoracic epidural catheters were found. In conclusion, continuous TEA with buprenorphine for postoperative pain relief after major abdominal surgery is a safe method without too high a risk of catheter-related or drug-induced complications, even on a normal surgical ward and when one clotting parameter is abnormal.

Iatrogenic spinal subdural haematoma

Spinal subdural haematoma is a rare condition, usually seen in association with lumbar puncture or a bleeding disorder. It carries a high morbidity and mortality, and successful treatment requires prompt surgical intervention. We present a case of mixed spinal subarachnoid and subdural haemorrhage complicating failed spinal anaesthesia combined with anti-coagulation in an elderly woman, together with a review of the literature.

Lumbar regional anaesthesia and prophylactic anticoagulant therapy. Is the combination safe?

A survey has been carried out in all Danish anaesthetic departments (n = 80) regarding the attitude towards the use of epidural/spinal lumbar analgesia in patients who were receiving prophylactic anticoagulant therapy for the prevention of thromboembolism. About 60% of the departments used the techniques in patients receiving low-dose heparin and no side effects had been experienced. Spinal and epidural anaesthesia were in general regarded as being contraindicated in patients fully anticoagulated with vitamin K antagonists. In the world literature, the attitude towards the combination is conflicting. No randomised trial has been performed and complications are almost entirely confined to patients fully anticoagulated with vitamin K antagonists. Only one case of an epidural haematoma has been recorded when subcutaneous low-dose heparin was used as thromboprophylaxis.

[Heparin and spinal or epidural anesthesia: decision analysis]

The incidence of thromboembolism justifies prophylactic measures, the most efficient of which is the use of heparin. However this agent may be responsible for haemorrhagic complications during regional anaesthesia. The risk of bleeding in a poorly accessible area, e.g. the epidural space, the brachial plexus sheet, the space behind the eyeball, is one of the concerns of anaesthetists. A review of case reports of haemorrhagic complications of spinal anaesthesia shows that the risk of bleeding or of spinal haematoma is very low. In fact, a blood or epidural vessel is punctured in 2.8 to 11.5% of cases of epidural anaesthesia, without any sequelae. Some authors suggest that low molecular weight heparin may be given to patients before spinal anaesthesia. In all cases, patients should be carefully assessed before, during and after the procedure, clinically and biologically. The absolute contra-indications to these techniques are a refusal by the patient, an uncooperative patient, severe coagulation disorders, untreated hypovolaemia, infection of the puncture site, severe generalized infection, and raised intracranial pressure. Decision as to whether a regional anaesthetic technique should be used in a particular patient who is under anticoagulant treatment, or who is to receive such a treatment intra or postoperatively, must be made on an individual basis. The risk of thromboembolism must be weighted against the risk of haemorrhagic complications. Unfortunately, in the absence of relevant studies, anaesthetists can only rely on their clinical judgment.

Epidurals, spinals and bleeding disorders in pregnancy: a review

Paraplegia caused by spinal haemorrhage is a very rare but disastrous complication of spinal or epidural insertion. The risk in uncomplicated surgical and obstetric patients is outlined. Bleeding disorders in pregnant patients may prevent the use of major regional anaesthesia. Factors which influence the choice of anaesthetic technique for patients with pregnancy-induced hypertension, von Willebrand's disease, and anticoagulation therapy, are discussed.

Postmortem findings after epidural anaesthesia

Postmortem specimens of 10 patients who had received continuous epidural anaesthesia postoperatively (ranging from 2-21 days) were examined. Slight epidural haemorrhage was observed in six patients and a macroscopically visible haematoma in a thrombocytopenic patient. Nonspecific epidural inflammatory reactions were observed microscopically in all patients. Specimens from seven patients with systemic infection showed signs of epidural infection. No similar pathology was found in a control group without epidural catheters. The aetiology and risk factors of the above findings are discussed, and recommendations given to prevent such sequelae after epidural anaesthesia.

Spondylitis without epidural abscess formation following short-term use of an epidural catheter

A 42-year-old patient had undergone total hip replacement for aseptic femoral head necrosis 9 years previously. He now presented with loosening of the prosthesis and pseudoarthrosis sustained following a femoral shaft fracture 7 months earlier. A total hip replacement was carried out in general anaesthesia combined with an epidural catheter. The epidural catheter was removed on the third postoperative day, after which the patient complained of persistent lumbar pain which was associated with meningismus, fever, leucocytosis and a raised erythrocyte sedimentation rate. In spite of intensive laboratory and radiological investigation, 15 weeks elapsed before a radiological diagnosis of spondylitis of L1 and L2 could be made. Aspiration biopsy of the L1/L2 disc space yielded a growth of Pseudomonas aeruginosa. Antibiotic therapy was begun immediately but could not prevent spread of infection to the adjacent disc-space T12/L1 and the vertebral body T12. The patient made a slow recovery and was discharged in a satisfactory condition wearing a lumbar brace some 9 months after the operation. No evidence of epidural abscess formation was found at any stage and no direct connection between the use of the epidural catheter and spondylitis could be established.