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Print version ISSN 0034-7094On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.2 Campinas Mar./Apr. 2007
Conservative treatment of hematoma after spinal anesthesia: case report and literature review*
Hematoma después de raquianestesia tratado conservadoramente: relato de caso y revisión de la literatura
Daniel SegabinazziI; Betina Comiran BrescianiniII; Felipe Gornicki SchneiderIII; Florentino Fernandes Mendes, TSAIV
Ex-ME do CET da FFCMPA
IIME3 do CET da FFCMPA
IIIGraduando em Medicina da FFCMPA
IVResponsável pelo CET-SBA da FFCMPA; Mestre em Farmacologia pela FFCMPA; Doutor em Medicina pela FMSCSP; Professor de Anestesiologia FFCMPA
OBJECTIVES: Spinal anesthesia caries the risk of bleeding. Compression of
nervous tissue secondary to the formation of a hematoma can cause neurological
damage, which, if not diagnosed and treated in a timely fashion, can be permanent.
The identification of risk factors, diagnosis, and early treatment are important
for the prognosis. The objective of this report was to describe the case of
a hematoma after spinal anesthesia treated conservatively, and review the literature.
CASE REPORT: Male patient, 73 years old, 65 kg, 1.67 m, and ASA physical status III, underwent spinal anesthesia for removal of a peritoneal dialysis catheter. During the puncture, the patient experienced paresthesia of the right lower limb. Fifteen milligrams of 0.5% hyperbaric bupivacaine without vasoconstrictor were administered. Twenty-four hours later, saddle anesthesia and lumbar pain persisted and, after 48 hours, the patient presented urinary incontinence. An MRI demonstrated the presence of an expansive subarachnoid process compressing the nerve roots (L4 and S1). After evaluation by the neurosurgeon, conservative treatment was instituted. The patient was discharged from the hospital on the 18th postoperative day, asymptomatic.
CONCLUSIONS: The case reported here presented a good evolution with the conservative treatment.
Key Words: ANESTHETIC TECHNIQUES, Regional: spinal block; COMPLICATIONS: hematoma.
JUSTIFICATIVA Y OBJETIVOS:
Durante la realización de anestesia espinal existe el riesgo de que ocurran
sangramientos. La compresión del tejido nervioso, secundaria a la formación
de hematoma puede determinar el aparecimiento de lesión neurológica
que, si no se diagnostica y se trata a tiempo, puede ser permanente. La identificación
de los factores de riesgo, el diagnóstico y el tratamiento precoz de
la compresión son importantes para el pronóstico del paciente.
El objetivo de este trabajo fue describir un caso de hematoma después
raquianestesia tratado de forma conservadora y revisar los trabajos en la literatura.
RELATO DEL CASO: Paciente del sexo masculino, 73 años, 65 kg, 1,67 m, estado físico ASA III. Fue sometido a raquianestesia para retirada de catéter de diálisis peritoneal. Durante la realización de la punción hubo parestesias en el miembro inferior derecho. Se inyectaron 15 mg de bupivacaína hiperbárica a 0,5% sin vasoconstrictor. Veinte y cuatro horas después de la realización del bloqueo el paciente permanecía con anestesia en silla de montar y con dolor lumbar, y 48 horas después del procedimiento presentó una incontinencia urinaria. La resonancia nuclear magnética demostró la existencia de un proceso expansivo subaracnoideo, con compresión de raíces nerviosas (L4 a S1). Después de la evaluación del neurocirujano, se empieza el tratamiento conservador. El paciente recibió alta hospitalaria el 18° día de postoperatorio asintomático.
CONCLUSIÓN: El caso presentado mostró una buena evolución con el tratamiento conservador.
Even when performed with the proper technique, spinal anesthesia carries the risk of bleeding. Compression of the nervous tissue secondary to the formation of a hematoma can cause neurological damage 1,2, which, if not diagnosed and treated in a timely fashion, can result in permanent damage 3.
After regional anesthesia, bleeding disorders are the greatest risk factors for the development of spinal hematoma 2,3, although there are other known factors, such as difficult or traumatic insertion of the needle. Due to the lack of randomized clinical trials, the risk of hematoma is unknown in patients receiving antithrombotic treatment 4-6. Considering that the incidence of hematoma is extremely low, those studies would have to include a large number of patients, above 100,000, which is not feasible. The literature stresses the importance of monitoring the patient, especially taking into consideration that retrospective analysis demonstrated that the early diagnosis and surgical treatment, in the first eight hours after the beginning of the symptoms, could prevent or decrease the intensity of neurological deficits 3-5.
Male patient, 73 years old, 65 kg, 1.67 m, ASA physical status III (chronic renal failure, hypertension, stenosis of the carotid arteries, and prior history of TIA) was admitted for removal of a peritoneal dialysis catheter due to signs of peritonitis. Laboratory exams showed hematocrit 34%, hemoglobin 10.9 g.dL-1, prothrombin time 86% (reference value from 70% to 100%), partial activated thromboplastin time 43.6 seconds (control 35 seconds reference < 1.3 times control), and creatinine 7 mg.dL-1. He underwent spinal anesthesia through a median puncture with a 25G Quincke needle in the L2-L3 space.
During the puncture, the patient complained of paresthesia in the right lower limb, which improved after a slight retrieval of the needle. The cerebrospinal fluid was clear. Fifteen milligrams of 0.5% hyperbaric bupivacaine without vasoconstrictor were administered. The surgical procedure was uneventful, and the patient was transferred to the recovery room. After five hours, the patient complained of paresthesia of the lower limbs, and in the dorsal and gluteal regions, without pain. Physical exam demonstrated partial bilateral motor blockade (partial flexion of the knees and total flexion of the feet). Neurological evaluation showed saddle anesthesia, hyposthesia in the right plantar region, and normal reflexes. Four hours after the initial evaluation, the clinical presentation remained unchanged, and a CT scan was done, which did not show any lesions in the lumbosacral spine. In another evaluation, 24 hours after the puncture, the patient remained with saddle anesthesia and complained of moderate lumbar pain. Although the strength in the lower limbs was normal, he could only walk with assistance. Forty-eight hours after the procedure, the patient presented urinary incontinence. An MRI of the spine revealed the presence of an expanding subarachnoid mass from L4 to S1, compression of the nerve roots, and an old fracture in T12. After neurosurgical evaluation, conservative treatment was instituted with physical therapy, analgesia with 750 mg of acetaminophen every six hours, and corticosteroids (dexamethasone initial dose of 20 mg IV and maintenance dose of 4 mg orally, four times a day for ten days). The patient was discharged from the hospital in the 18th postoperative day, asymptomatic. Thirty days after discharge, an MRI showed normal spinal cord cone and medullary canal.
DISCUSSION AND LITERATURE REVIEW
Spinal anesthesia has advantages, such as reduced blood loss, and decreased incidence of deep venous thrombosis 7 and pulmonary complications 8. Large series demonstrated it is a safe procedure 3,9,10. The possibility of a hematoma (subarachnoid or epidural) is a source of concern for the anesthesiologist, because it can cause permanent deficits. Almost every case described involves patients that underwent spinal anesthesia and developed paraplegia. Typically, it begins with severe lumbar pain, which progresses to flaccid paralysis. Sensory changes usually occur after the motor changes, and surgical intervention, CT scan, MRI, or necropsy confirm the presence of a large mass compressing the spinal roots 10.
A literature review from 1911 to 1981 found 34 cases of subarachnoid hematoma.
According to the authors, only two patients did not have a history of bleeding disorders. In this series, four of the patients who developed epidural hematoma bled during the puncture and two were described as technically difficult 11. In a population of approximately 750,000 patients, Usubianga found eight epidural hematomas. Four of them received IV heparin after the blockade, in three the puncture was traumatic with bleeding, and only one did not have risk factors 1.
Several risk factors have been implicated in the physiopathology of subarachnoid hematomas, especially bleeding disorders. A study on subarachnoid hematoma post-lumbar puncture reviewed 26 cases reported in the literature 12. Most of them presented the following situations: association with antithrombotic therapy, thrombocytopenia, delay in diagnosing compressive syndrome of the spinal cord and nerve roots, need for surgical treatment, good postoperative outcome in half of the patients, and the prognosis was somber for patients with prior severe disease. Besides, it was verified that the risk to develop this type of complication could be high in patients with leukemia, especially in those with a tendency for thrombocytopenia (less than 25,000 platelets/mm3).
In 69 cases reviewed in a meta-analysis considered the etiology, diagnosis by imaging exams, and results of the treatment both conservative and surgical. The most common causes of subarachnoid hematoma were bleeding disorders (40.5%), including those induced pharmacologically, those that resulted from systemic diseases, diagnostic or anesthetic lumbar puncture (44.9%), and trauma (15.9%). The mortality rate was of 25.7%. Long-term followed up was possible in 50 cases. The surgical treatment was more common, with a good result in 93.5% of the 31 patients who presented a satisfactory neurological status on admission, and in 15.8% of those patients who presented severe neurological deficits upon admission 13. Thus, according to the authors, the result of the treatment depends on the initial neurological status of the patient, the degree of co-morbidities, the location of the hematoma, and eventual association with subdural hematoma 13.
In another study, Castillo et al. reviewed 20 cases reported in Spain 14. Eight of them were related with spinal anesthesia, eight occurred during epidural anesthesia, one during combined anesthesia, and one with diagnostic lumbar puncture. Risk factors that might have been the cause of this complication were identified in 11 cases, and in seven of them, the catheter was manipulated during the period of hemorrhagic risk due to antithrombotic treatment 14,15. Of the cases studied, eleven patients were treated surgically and the remainder with conservative treatment, with drugs and physical therapy. The neurological outcome was satisfactory in 14 cases (70%), which was considered a good result.
Surgical decompression is considered necessary in the treatment of epidural hematoma to prevent permanent neurological deficits 4,14-18. There were very few cases of spontaneous resolution of epidural hematoma published 19-21. Regardless of the cause, urgent decompressive laminectomy should be done in patients with epidural hematoma and signs of compression of the spinal cord. Lawton et al. reported that early diagnosis and urgent surgical treatment improve the possibility of neurological recovery, and that patients with complete nervous lesions or chronic spinal cord compression have better results with the surgical treatment 22. It is important to stress that the prognosis of the surgical treatment is related to time. The neurological outcome of the patient undergoing laminectomy depends on how long symptoms have been present. It is known that surgical decompression more than eight hours after the beginning of the symptoms is associated with a worse prognosis. Therefore, urgent laminectomy is very important for the improvement of the patient 23,24.
However, surgical treatment might not be necessary when the clinical symptoms do not evolve or when there is early improvement. There are cases of patients with epidural hematoma, both post-traumatic and spontaneous, in which the conservative treatment was satisfactory 25. The initial regression of the symptoms might be an indication for institution of the conservative treatment 26. Wagner et al. showed that, in patients with stable injuries, or in those whose neurological status is improving, conservative treatment and monitoring with MRI can be the treatment of choice 20.
In this case, neurological evaluation was done 48 hours after the block. Conservative treatment, with monitoring of the neurological status, was the choice. Since the patient presented a favorable evolution, the conduct was maintained. We did not find in the studies objective and reliable parameters that define when the conduct should be surgical or conservative. Thus, the severity of the symptoms, the evolution of the clinical status, imaging exams, and the experience of the team can orient whether decompression is necessary or not. To identify an expanding mass compressing the spinal cord or nerve roots, MRI is the imaging exam more accurate, and the myelotomography has better results than CT scan 25,27. In the hospital where this case was diagnosed, MRIs are done at another institution through an agreement, and the access is restricted. This is why a CT scan was initially done.
Paresthesia during the anesthetic block is an important predictive sign 28. The main symptoms of nerve root compression include hyposthesia and regional weakness in the area of the involved nerve root. If paresthesia persists, one should suspect of direct trauma by the needle or catheter. Auroy et al. reported 19 cases of nerve root compression, 12 of which presented paresthesia during the spinal block. Besides, two patients complained of severe pain 29. Yoshii et al. reported seven cases of persistent paresthesia after epidural anesthesia in obstetric procedures. Of those, two patients did not present resolution of the symptoms and in two the symptoms lasted for more than one month. They all experienced paresthesia during the insertion of the epidural catheter 30. In an expressive series, reported by Horlocker et al., 300 out of 4,767 spinal blocks (6.3%) presented paresthesia during the injection of the local anesthetic. Six cases (1.2%) had persistent symptoms. Four of those (66.6%) had paresthesia during the administration of the local anesthetic. The incidence of persistent paresthesia was of 1:75 in the group with symptoms during the procedure and 1:2,200 in the other group 31. In a study with 130 patients by Knowles et al., the incidence of paresthesia was 8.5% 32. These data show the predictive value of paresthesias as a negative event regarding the development of postoperative nerve root disease.
In this case, it is hard to correlate the complaint of paresthesia during the insertion of the needle with the neurological symptoms that the patient developed. The symptom is usually unilateral and, when the lesion affects more than one nerve root, it is a strong suggestion that the needle damaged the cone of the spinal cord 33. Although several anesthesiologists think they can identify the lumbar intervertebral space precisely, van Gessell et al. 34 demonstrated that 59% of the dura mater punctures were done one or two intervertebral spaces above the one the physician imagined. More recently, Broadbent et al. 35, studying a group of experienced anesthesiologists who believed they had identified the L3-L4 space, verified that in 85% of the cases, the space selected was one to five segments higher 35. Thus, due to the lack of precision of the method used to identify the lumbar intervertebral space, and the variability in the localization of the spinal cord cone, the hypothesis of direct spinal cord lesion caused by the tip of the needle cannot be discarded. However, the expansive lesion, demonstrated by the MRI, and the fact that the symptoms were bilateral, discard this hypothesis 33.
In conclusion, conservative treatment of subarachnoid hematoma with good clinical evolution, depends on the initial neurological status of the patient and its evolution. We did not find in the literature parameters to orient the safest conduct when choosing between the surgical and conservative treatments.
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Dr. Florentino Fernandes Mendes
R. Osmar Amaro de Freitas, 200
91210-130 Porto Alegre, RS
Submitted em 19
de abril de 2006
Accepted para publicação em 12 de dezembro de 2006
* Received from Serviço de Anestesiologia da Santa Casa de Porto Alegre da Faculdade Federal de Ciências Médicas de Porto Alegre (SCPA FFCMPA), Porto Alegre, RS