Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome

Good outcome with conservative treatment of delayed spinal epidural hematoma following combined spinal-epidural anesthesia: a rare case report

BACKGROUND

Delayed spinal epidural hematoma (SEH) following central neuraxial block (CNB) is a rare but serious complication. The underlying causes of SEH associated with neuraxial anesthesia are still unclear. Furthermore, the decision between surgical intervention and conservative management for SEH remains a complex and unresolved issue.

CASE PRESENTATION

We report a case of delayed SEH in a 73-year-old woman who underwent vaginal hysterectomy under combined spinal-epidural anesthesia, with the administration of postoperative anticoagulants to prevent deep vein thrombosis on the 1st postoperative day (POD). She experienced symptoms 56 h after CNB. Magnetic resonance imaging (MRI) revealed a dorsal SEH at the L1-L4 level with compression of the thecal sac. On conservative treatment, full recovery was achieved after six months.

CONCLUSIONS

This case reminds anesthesiologists should be alert to the possible occurrence of a delayed SEH following CNB, particularly with the administration of anticoagulants. Immediate neurological evaluation of neurological deficit and MRI are advised. Conservative treatment combined with close and dynamic neurological function monitoring may be feasible for patients with mild or nonprogressive symptoms even spontaneous recovery.

Spontaneous spinal epidural hematoma (SSEH) after cesarean section under epidural anesthesia: A case report

Spontaneous spinal epidural hematoma (SSEH) is an uncommon condition that can lead to severe neurological injuries, often accompanied by back pain. Pregnancy is identified as a risk factor for SSEH. Early diagnosis of SSEH presents challenges due to its atypical manifestations and the use of intraspinal anesthesia and analgesic techniques. In this case, we present the instance of a 29-year-old woman who initially received epidural labor analgesia during the first stage of labor but subsequently required a cesarean section under epidural anesthesia according to amniotic fluid turbidity. Unfortunately, the anomalous recovery of neurological function in her left lower extremity was not given sufficient attention at an early stage, and paralysis in the non-puncture segment occurred 45.5 hours after the initial puncture. Interestingly, she did not experience any back pain during these procedures. MRI examination and consultation with neurosurgeons confirmed the diagnosis of SSEH, prompting the patient to undergo emergency decompression surgery. She made an incomplete recovery 17 months after the operation. This case emphasizes the importance of considering the possibility of SSEH in pregnant women undergoing epidural analgesia, highlighting the need for spinal imaging and early neurosurgical interventions to facilitate treatment.

The Necessity of Extensive Decompression for Spinal Epidural Hematoma: A Case Report and Literature Review

Spinal epidural hematomas (SEHs)are space-occupying lesions that exert pressure on the spinal cord by rapidly accumulating blood between the dura and bone or ligament components. The annual incidence of spontaneous epidural hematoma is estimated to be one in one million. The predominant symptoms are back pain or neurological impairment, including sensory, motor, or autonomic dysfunction of the limbs below the hematoma level. Depending on the level and size of the hematoma and the affected cord, they cause neurological deficits. Neurological deficits are often reversible if diagnosed and treated early with surgical decompression. However, neurological deficits can become permanent if the patient is not operated on timely, and paraplegia or quadriplegia may occur. A 53-year-old man presented to our emergency department with acute-onset back pain and 36-hour-long, rapidly progressive paraparesis of both legs. On T1- and T2-weighted MRI scans, a hyperacute SEH was found as iso/hyperintense and hyperintense, respectively. Immediate decompressive laminectomy from T10 to L2 and hematoma evacuation were performed. It was challenging to remove the hematoma due to its firm consistency. Before performing a bilateral total laminectomy at five levels, the posterior spine was stabilized between T10 and L3 using transpedicular screws. Within 24 hours, the motor function of the lower limbs increased considerably. The patient could sit on a chair because of posterior stability. In addition to the importance of early diagnosis using imaging techniques, planning the extension of SEH surgery is crucial for the patient's postoperative neurological recovery.

Massive Acute Spinal Subdural Hematoma Causing Sudden Onset Paraplegia in a Patient on Anticoagulation

Spinal subdural hematoma (SSDH) is a rare but known entity that can cause severe and irreversible motor, sensory, and autonomic dysfunction if not decompressed in a timely manner. We present here a 74-year-old female on anticoagulation who developed sudden onset back pain with rapidly progressive paraplegia. On neurologic exam, she was completely flaccid in the bilateral lower extremities with absent sensation from the umbilicus down. Imaging demonstrated a massive extra-axial spinal hematoma from T12 to S1 that initially was believed to be epidural in origin. She was taken emergently to the operating room for a T11-L5 decompressive laminectomy, and dural opening demonstrated a thick subdural clot encasing the conus and cauda equina confirming the subdural pathology. Despite decompression and partial evacuation of the subdural hematoma, she did not recover neurologic function.