Background: Spinal haematoma(SH) is a rare but potentially catastrophic complication of neuraxial anaesthesia(NA). The authors present a case of a patient who developed a SH after combined spinal–epidural anaesthesia.

Case report: 85 yr, woman, ASA physical status II, scheduled for femoropopliteal bypass. The patient was not medicated with anti-platelet drugs and coagulation panel was normal. After standard ASA monitoring, ST segment analysis and invasive blood pressure monitoring, the patient underwent combined spinal–epidural anaesthesia by an experienced anaesthesiologist at L4-L5 space, first attempt, using a 27G spinal needle and a 18G epidural needle. 40 minutes after NA, 5000 U of heparin were administered. Intraoperative and postoperative period were uneventful.
At 2nd postoperative day, patient complained of low back pain with epidural injection of local anesthetic which was immediately suspended. After 3h45m motor and sensitive block of right leg ensued, followed by contralateral limb block. Immediate MRI was undertaken: “posterolateral epidural collection extending from D10 to D12 on the right and another from D12 to L2 on the left...narrowed lumbar canal”. An emergent decompressive laminectomy was performed, 5h51m after the first symptom, without complications with total recovery of motor strength, bilaterally. 

Discussion: The incidence of SE as a result of NA is unknown. Among the known risk factors our patient presented advanced age, narrowed lumbar canal and administration of heparin during the procedure. Prognosis is mainly dependent of the severity of symptoms and the time elapsed between the appearance of symptoms and surgical treatment, and spinal cord ischaemia tended to be reversible in patients who underwent laminectomy within 8h-12h of neurological dysfunction.

References: 1-doi:10.1093/bja/aeu461,2015; 2-doi:10.1093/bja/aen170

Learning points: Despite its rarity, the awareness of this complication must be present in all patients who undergo NA approach. Immediate MRI should be considered at a low threshold when a new neurologic dysfunction arises. Prompt identification and intervention may contribute to a successful neurological outcome.

Spinal haematoma - a rare complication of epidural catheterization