RevBrasAnestesiol.2016;66(5):533---535
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Spinal
subarachnoid
haematoma
after
spinal
anaesthesia:
case
report
Marion
Vidal
a,
Antoine
Strzelecki
a,
Mireille
Houadec
a,
Isabelle
Ranz
Krikken
a,
Antoine
Danielli
a,
Edmundo
Pereira
de
Souza
Neto
a,b,c,∗aCentreHospitalierdeMontauban,Montauban,France
bCNRS,LaboratoiredePhysique,EcoleNormaleSupérieuredeLyon,Lyon,France
cUniversidadedoOestePaulista(UNOESTE),SãoPaulo,SP,Brazil
Received9March2015;accepted17August2015 Availableonline21January2016
KEYWORDS
Subarachnoid haematoma; Spinalanaesthesia; Riskfactors
Abstract Subarachnoidhaematomaafterspinalanaesthesiaisknowntobeveryrare.Inthe majorityofthesecases,spinalanaesthesiawasdifficulttoperformand/orunsuccessful;other riskfactorsincludedantiplateletoranticoagulationtherapy,anddirectspinalcordtrauma.We reportacaseofsubarachnoidhaematomaafterspinalanaesthesiainayoungpatientwithout riskfactors.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Hematoma subaracnoideo; Raquianestesia; Fatoresderisco
Hematomaespinhalsubaracnoideoapósraquianestesia:relatodecaso
Resumo Hematomasubaracnoideoapósanestesiaespinaléconhecidoporsermuitoraro.Na maiordessescasos,aanestesiaespinalfoidifícildeexecutare/oumalsucedida;outrosfatores deriscoincluemterapiaanticoagulanteouantiplaquetáriaetraumamedulardireto.Relatamos
umcasodehematomasubaracnóideoapósraquianestesiaempacientejovemsemfatoresde
risco.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum
artigo OpenAccess sobumalicenc¸aCCBY-NC-ND(
http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:[email protected]
(E.P.SouzaNeto).
Introduction
Subarachnoidhaematomaafterspinalanaesthesiaisknown tobe very rare.1---3 In the majority of these cases, spinal anaesthesiawasdifficult toperform and/or unsuccessful;
http://dx.doi.org/10.1016/j.bjane.2015.08.001
534 M.Vidaletal.
other risk factorsincluded antiplatelet or anticoagulation therapy,anddirectspinalcordtrauma.2,3Wereportacase of subarachnoidhaematoma after spinal anaesthesia in a youngpatientwithoutriskfactors.
Case
report
Malepatient,32yearsold,72kg,180cm,whopresentedfor openinguinal herniarepair. Pastsurgical historyconsisted ofsomeminorsurgeriesunderlocalanaesthesiaandanasal operationundergeneralanaesthesia.Thepatienthada neg-ativepast medicalhistory, nohistoryof abnormalclinical bleedingandwasnottakinganymedications.HisASA phys-icalstatusclassificationwasone.
Forthisoperation,the patientrequested spinal anaes-thesia at the preoperative anaesthetic consultation. Following French Society of Anaesthesia and Intensive Carerecommendation,nopre-operative investigation was requested.4
Thepatientwasplacedinasittingposition.Spinal anaes-thesiawasattemptedattheL3-4intervertebralspaceviaa midlineapproachusingaBDTMWhitacre25Gspinalneedle withpencilpoint.Atthefirstattempt,clearcerebrospinal fluidwasobservedwithoutanyparticulardifficulties.
Hyperbaric bupivacaine 0.5% 2.0mL was injected. Intrathecal needle tipplacement was confirmed prior to, duringandafterinjectionbyfreeaspirationofcerebrospinal fluid. No incidents such as blood or paraesthesia were reported. Loss of sensation to cold touch was used to determinethedermatomeleveloftheblockwhichwasT8 bilaterally.
The surgery began 10min afterspinal anaesthesia was performed and lasted20min without any problems. Intra operatively,atotalof80mgofpropofolwasgivenfor seda-tion,aswellas2gofcefazolinforantimicrobialprophylaxis, 8mg of dexamethasone, 100mg of ketoprofen, 20mg of nefopamand1gofacetaminophen.
Thepatientremainedinthepost-anaesthesiacareunit foronehourandthenreturnedtotheward.The Modified AldreteScoringSystemwas10.Noprophylaxiswasgivenfor deepveinthrombosis.Hewasdischargedfromthehospital intheafternoonandthepost-anaestheticdischargescoring systemwas9.
Onthe9thpostoperativedayhepresentedtothe Emer-gencyDepartmentcomplainingofintense lowerback pain for 3 days, radiating to both legs following L5-S1 sensi-tiveterritoryassociatedwithparesthesia.Thesesymptoms beganwithhypoesthesiaoftheperineumonthefirst post-operativedayandgraduallyworsenedleavinghimunableto walk.Furtherinvestigationbytheneurologistrevealedthat thesensoryblocklastedmorethan24hafterdischarge.
Neurologicalexaminationrevealednolossofpower, sen-sationorsphinctercontrolbutlossofreflexesinthelower limbs.The pain wasreproducible on clinical examination and needed level 3 analgesic drugs to be soothed. Since caudaequinasyndromewassuspectedamagneticresonance imaging(MRI)wasperformed.Itrevealeda35mm×8.5mm
subarachnoidhaematomaatlevel L4-L5associatedwitha small epidural haematoma at the cauda equina with no damagetothefilum (Fig.1). The lumbarcanal waslarge and there was no meninges abnormality. There was no
Figure 1 T1 weighted sagittal MRI showing subarachnoid haematoma regardingL4-L5associated with asmall epidural haematomaregardingthecaudaequinawithnodamagetothe filum.
abnormalityinthecoagulationprofileandnoinflammatory syndrome.Subarachnoidhaematomadiagnosiswasretained andaneurosurgeonwasconsulted.Nosurgicalintervention wasneededsothepatientwashospitalizedfor3daysin neu-rology for conservative treatment and pain management. He wasthendischargedwithpaintreatment consisting of opioids, nonsteroidal anti-inflammatory and pregabaline. Follow-upat onemonth revealedresiduallowerbackpain withradiationtotheknees,walkinglamenessandstifflower back.Therewasnomorelossoflowerlimbsreflexes.AnMRI controlscanrevealednosignsleftoftheinitialhaematoma andnonervedamage.
Discussion
Spinalsubarachnoidhaematomaafterspinalanaesthesia:casereport 535
malformations represent the first, second and third most commoncategoriesrespectively.1
In a Finland study incidence of neuraxial haematoma afterspinalblockwas1:775,000.2 Theyreportedonecase of subarachnoidhaematoma afterspinal block. A 67year oldwomanadmittedfor arthroscopy.Spinalstenosismight havecontributedtotheneurologicsymptomsforthelatter case.Smallspaceduetoherniation,arachnoidites,spondylo atrodic process, or thickening of the ligamentum flavum leadingtolowercirculationofcerebrospinalfluidand con-tributingtotheformationofsubarachnoidhaematoma.
Bleedinginthesubduralspacecouldbealsorelatedto punctureoftheradiculomedullaryvesselsfoundalong the nerveroots andmay bepunctured especiallyif thepoint of the needle is notin the mid line.7 Other predisposing factorsincludethenumberofpunctures,multiple degener-ativediscopathy,andspinalstenosis.8---11Thecasewereport is highly unusual since subarachnoid haematoma is very uncommoninpatientsasyoungas32yearsold.12Inourcase, allpreoperativerecommendations werefollowed.No con-tributing factor has been identifiedandno incidentssuch asbloodor paraesthesiawerereported.Nospinalstenosis was spotted on the MRI; only an atraumatic single mid-linepuncturewitha25GWhithcareneedlewasperformed. Noantiplatelet,anticoagulation or coagulopathydisorders wereinvolved.
However,probablyneedlesizeandshapecouldinfluence spinalsubarachnoidhaematomabecausefineneedles(27G and29G),mayhavelessvesselstraumatisesalongthelength ofnerveroots.13,14Someauthorssuggestthatsubarachnoid haematomaoccurswhenradicularvesselsarelaceratedby traumaticlumbar puncture.13,14 Bloodin thesubarachnoid spaceusuallydoesnotclot,probablybecauseofthegreat dilutionbyspinalfluid.Defibrinationofbloodfromthe pul-satilemotionderivedfromthebrainandspinalcordmaybe anadditionalfactor.11,13,14
Typical symptomsof subarachnoidhaematomainclude: spinal root pain, lombalgia, paraparesis, sphincter dys-function andheadache that does not fulfilthe criteriaof postduralpunctureheadache(PDPH).Clinicalpresentation of intraspinal haematoma may vary from persistent back pain to frank paraplegia.15 Recommended treatment for symptomatic compression of nerves is emergency spinal laminectomy within 6h. But absence of clinical signs of compressionshouldleadtomedicaltreatmentinaccordance withneurosurgeonapproval.
Earlydiagnosisisthekeytofullrecoveryofsubarachnoid haematoma.When suspected,according to the historyof spinalanaesthesiaandtypicalsymptoms,anemergencyMRI shouldbeperformed.Computedtomographicscannerdoes notgiveconclusiveresults;onlyMRIcanconfirm the diag-nosisofsubarachnoidhaematoma,itslocalization,sizeand compressionofthefilum,ifpresent.Italsodetectsvascular lesionsorassociatedmalformation.
A headache following an intradural puncture should leadtosuspicion ofdifferential diagnosis includingPDPH, drug related headache, intracranial hypertension, menin-gitis, thrombosis of intracranial veins, cerebral abscess,
subduralorsubarachnoidhaemorrhageaswellas subarach-noidhaematomaevenifrare,shouldbeborneinmind.
Takingintoaccountallpredisposingfactorsofspinal sub-arachnoidhaematomaafterspinalanaesthesia,nonewere found in our case. The probability of having such a case is extremely rare but possible evenif guidelines for safe practicearefollowed.Any clinical suspicionabout sucha case should lead to MRI immediately in order to confirm diagnosis andtreat beforesevere permanentneurological damageoccurs.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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