A Problem-Based Learning Discussion

A 68-year-old female with a past medical history of atrial fibrillation, for which she takes dabigatran, presented with six months of lower back pain with radiation to her bilateral lower extremities. MRI of the lumbar spine revealed severe canal and foraminal stenosis at L2-L3. After stopping dabigatran for seven days, she received a central epidural steroid injection with 1.5 mL of triamcinolone (40mg/mL) and 1 mL of bupivacaine (0.5%) into the L2-L3 space. The patient tolerated the uncomplicated procedure well and immediately noted substantial improvement in her pain. After 24 hours, the patient resumed dabigatran. Forty-eight hours following the procedure, the patient complains of bilateral lower extremity numbness.¹

1. How will you evaluate this patient? What is your differential?

a. Spinal epidural hematomas (SEH) are a rare complication following epidural steroid injections which can lead to devastating complications including paralysis. Hence, this situation requires prompt investigation with a complete neurologic assessment and further imaging studies to confirm a diagnosis.

b. Spinal epidural abscess can have a similar presentation. Clinically, the presence of fever and increased white counts can point towards an infectious origin.

c. Other coincidental causes of sudden onset bilateral lower extremity weakness including acute transverse myelitis and Guillain-Barré syndrome can be considered once the above complications are ruled out.

Upon initial examination, the patient had nearly complete paraplegia of her bilateral lower extremities.

2. How do we diagnose a spinal epidural hematoma?

a. If, within 24-48 hours of an inciting event, the patient develops new focal neurologic deficits and palpable back pain over the site of an intervention,² diagnostic imaging studies are indicated.

3. What is the pathophysiology of SEH?

a. Spinal epidural hematoma can arise spontaneously and 40%-60% of these cases are idiopathic. Others are attributable to a variety of factors including hemophilia, hypertension, and arteriovenous malformation.³ SEH can also arise after spine surgery and neuraxial anesthesia due to epidural venous plexus trauma by a needle or catheter.⁴ Rarely, acupuncture has been implicated.⁵

b. Blood accumulates in the epidural space, compressing the spinal cord, which leads to acute neurological deficits.³

4. How frequently do intraspinal epidural hematomas occur?

a. The literature so far only reports 15 cases of spinal epidural hematoma following epidural steroid injection.¹

b. After epidural anesthetics, estimates of the rate of epidural hematoma range from one in 150,000 to one in 2,700. In patients with abnormal coagulation, the rate may be as low as one in 315 epidural anesthetics. After spinal anesthetics, the rate is estimated to be one in 220,000 patients.⁶

5. Which factors put this patient at risk of an epidural hematoma?

a. Coagulopathy: Anticoagulation therapy (one quarter to one-third of all cases) and coagulation disorders including hemophilia, liver disease, and thrombocytopenia.

b. Technically difficult neuraxial procedures. Multiple punctures or anatomic abnormalities increase risk.

c. Higher risk in older adults.⁷ Lower risk in obstetric patients, likely due, in part, to hypercoagulability in pregnancy.⁶

6. What are the next steps in the management of this patient?

a. Frequent neurological checks

b. Consult neurosurgery

c. MRI spine

d. CBC and coagulation panel²

7. An MRI revealed an acute stenotic lesion centered at T12-L2, which has not been present on the previous MRI. Neurosurgery was consulted and the patient was immediately taken to the operating room for lumbar decompression. Which management decisions might improve the outcome of this case?

a. Neurologic outcomes are significantly worse when surgical decompression is delayed more than 12 hours.⁸ For poor surgical candidates or those who refuse surgery, an ultrasound-guided core needle biopsy can determine whether the hematoma is liquid, in which case it may be managed by an alternative form of treatment such as a lumbar puncture.⁹

8. What is the prognosis for a spinal epidural hematoma?

a. Approximately half of patients do not fully recover, and the degree of recovery is correlated with the degree of initial neurologic insult.⁸ Spinal cord function is sometimes measured by the Frankel system.¹⁰ There is a 5.7% mortality rate after spontaneous epidural hematoma, to which sub-optimal management is a significant contributor.³

References

1. Caputo AM, Gottfried ON, Nimjee SM, et al. Spinal epidural hematoma following epidural steroid injection in a patient treated with dabigatran: a case report. JBJS Case Connect. 2013;3(2 Suppl 9):e64. https://www.doi.org/10.2106/JBJS.CC.M.00011
2. Nelson A, Benzon HT, Jabri RS. Diagnosis and Management of Spinal and Peripheral Nerve Hematoma. NYSORA. https://www.nysora.com/foundations-of-regional-anesthesia/complications/diagnosis-management-spinal-peripheral-nerve-hematoma/. Published June 24, 2018. Accessed March 23, 2021.
3. Raasck K, Habis AA, Aoude A, et al. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043. Published 2017 Feb 2. https://www.doi.org/10.1038/scsandc.2016.43
4. Liu H, Brown M, Sun L, et al. Complications and liability related to regional and neuraxial anesthesia. Best Pract Res Clin Anaesthesiol. 2019;33(4):487-497. https://www.doi.org/10.1016/j.bpa.2019.07.007
5. Domenicucci M, Marruzzo D, Pesce A, et al. Acute spinal epidural hematoma after acupuncture: personal case and literature review. World Neurosurg. 2017;102:695.e11-695.e14. https://www.doi.org/10.1016/j.wneu.2017.03.125
6. Benzon HT, Jabri RS, Zundert TCV. Neuraxial anesthesia & peripheral nerve blocks in patients on anticoagulants. In: Hadzic A, ed. Hadzic’s Textbook of Regional Anesthesia and Acute Pain Management. 2^nd ed. McGraw-Hill Education; 2017.
7. Torres A, Acebes JJ, Cabiol J, et al. Revisión de 22 casos de hematomas epidurales espinales. Factores pronósticos y manejo terapéutico [Spinal epidural hematomas. Prognostic factors in a series of 22 cases and a proposal for management]. Neurocirugia (Astur). 2004;15(4):353-359. http://www.doi.org/10.1016/s1130-1473(04)70467-4
8. Bos EME, Haumann J, de Quelerij M, et al. Haematoma and abscess after neuraxial anaesthesia: a review of 647 cases. Br J Anaesth. 2018;120(4):693-704. https://www.doi.org/10.1016/j.bja.2017.11.105
9. Messerer M, Dubourg J, Diabira S, et al. Spinal epidural hematoma: not always an obvious diagnosis. Eur J Emerg Med. 2012;19(1):2-8. http://www.doi.org/10.1097/MEJ.0b013e328346bfae
10. Fang M, Zhou J, Yang D, et al. Management and outcomes of spinal epidural hematoma during vertebroplasty: case series. Medicine (Baltimore). 2018;97(21):e10732. http://www.doi.org/10.1097/MD.0000000000010732