Krwiak podtwardówkowy jako powikłanie połączonego znieczulenia podpajęczynówkowego i zewnątrzoponowego

Mariusz Golachowski

Summary
Background. The frequency of serious neurological deficits following neuraxial blocks are estimated at 5: 1000000 after subarachnoid anaesthesia and 7:1000000 after epidural anaesthesia. These rare, but potentially fatal complications, may be caused by haematoma formation and pressure of the spinal cord and/or nerve roots. Case report: A 74-yr-old woman received combined spinal-epidural anaesthesia with bupivacaine for total hip replacement. Enoxaparine sodium was used for perioperative thrombosis prophylaxis. Forty-eight hours after surgery, the patient reported sensations within lower part of her body and a lower extremity neurologic deficit was diagnosed. Epidural catheter was removed, enoxaparine was stopped and CT-scan was performed, suggesting a possibility of Th₁₂-L₃ subdural haematoma existence. MRI was not done at this stage. The patient was treated conservatively without improvement for 10 days; after that MRI was performed, revealing a spinal haematoma, extending from Th₁₂ to S₂, and compression of the spinal cord. Twenty-four days after anaesthesia laminectomy was eventually performed at L₂-L₃ level, but the neurosurgeon could not localize the haematoma; two weeks later, after further investigations, the surgery was repeated and a large haematoma, localized around cauda equina, was removed. Patient made good recovery and no neurological sequelae were observed. Discussion. A spontaneous spinal epidural haematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Early diagnosis and treatment are very important for the functional recovery of the patient. Spinal MRI is the most suitable neuroradiological method for early diagnosis and the surgical evacuation of the spinal/epidural haematoma via laminectomy should be performed within 8 hours from first symptoms.

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