Spinal epidural hematoma

When neuraxial anesthesia (epidural/spinal anesthesia) or spinal puncture is employed, patients who are anticoagulated or scheduled to be anticoagulated with low molecular weight heparins (LMWHs) or heparinoids for prevention of thromboembolic complications are at risk of developing an epidural or spinal hematoma, which can result in long-term or permanent paralysis. 

Increased risk of spinal/epidural hematomas with neuraxial anesthesia or spinal puncture. Risk is further increased by use of indwelling spinal catheters, repeated/ traumatic epidural/spinal puncture, or use of drugs affecting hemostasis (NSAIDs, anticoagulants, platelet inhibitors). 

A highly unusual case of thoracic epidural hematoma after spinal manipulation of the lumbar spine has been reported (186). 

Tseng SH, Chen Y, Lin SM, Wang CH. Cervical epidural hematoma after spinal manipulation therapy case report. J Trauma 2002 52(3) 585-6. 

RueUe A, Datti R, Pisani R. Thoracic epidural hematoma after spinal manipulation therapy. J Spinal Disord 1999 12(6) 534-6. 

Litz RJ, Gottschlich B, Stehr SN. Spinal epidural hematoma after spinal anesthesia in a patient treated with clopidogrel and enoxaparin. Anesthesiology (2004) 101, 1467-70. 

Neuraxial anesthesia and postoperative indwelling epidural catheter use Spinal or epidural hematomas, which may result in long-term or permanent paralysis, can occur with the use of anticoagulants and neuraxial (spinal/epidural) anesthesia or spinal puncture. The risk of these events may be higher with postoperative use of indwelling epidural catheters or concomitant use of other drugs affecting hemostasis, such as NSAIDs. 

Rose KD, Croissant PD, Parliament CF, Levin MB. Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic ingestion a case report. Neurosurgery 1990 26 880-882. 

Warfarin Garlic (Allium sativum) Increased INR Postoperative bleeding and spontaneous spinal epidural hematoma have been reported with garlic alone garlic causes platelet dysfunction... 

The most serious complication of neuraxial block (epidural or spinal anesthesia) is spinal hematoma with resulting paraplegia, Based on the pharmacokinetic and pharmacodynamic profile of... 

Libman RB, Wirkowski E, Alvir J, Rao TH (1995) Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol 52 1119-1122 Lin IY (2004) Diagnostic pitfall nontraumatic spinal epidural hematoma mimicking a brainstem stroke. Ann Emerg Med 44 183-184... 

A systematic review of all prospective studies of the risks associated with spinal manipulation included five primary investigations (150). The most valid studies suggested that about half of all patients who see a chiropractor will have adverse effects, which are usually mild and transient. No reliable data about serious adverse events were uncovered. However, a review of recent case reports has shown that spinal manipulation was associated with several serious adverse effects, including dissection of the vertebral and internal carotid arteries, resulting in strokes and at least one death (151). Other instances relate to epidural hematoma, intracranial aneurysm, cauda equina syndrome, contusion of the spinal cord, myelopathy, radiculopathy, and palsy of the long thoracic nerve. 

A 67-year-old woman had spinal manipulation for neck pain and experienced severe pain (182). She subsequently noted weakness of her left side, which worsened rapidly and also affected bladder function. She had a left-sided ptosis, all sensation was impaired below C6, and she had urinary incontinence. An MRI scan showed an epidural hematoma in the left posterolateral aspect of the spinal cord at C3-C5. Laminectomy was performed and a large epidural hematoma was removed. She subsequently made a full recovery. 

A 64-year-old woman experienced acute severe pain and progressive neurological defects for the first time during spinal manipulation. Swift surgical intervention was initiated and a thoracic epidural hematoma was evacuated. This resulted in complete recovery. 

A spontaneous spinal epidural hematoma resulting in paraplegia in an 87-year-old patient was attributed to chronic excessive use of garlic cloves (5). 

Permanent or temporary deficits of spinal cord function are caused either by cord ischemia after arterial hypotension, or by cord compression due to an epidural or subdural hematoma or infection, or injury to the spinal cord and nerve roots as a consequence of needle puncture, introduction of a catheter, or chemical irritation. 

The primary adverse effect associated with fondaparinux therapy is bleeding." " The rate of major bleeding in the VTE prophylaxis trials was approximately 2% to 3%. The risk of major bleeding appears to be related to weight therefore, in patients who weigh less than 50 kg, fondaparinux is contraindicated for VTE prophylaxis, and the treatment dose is only 5 mg every 24 hours. Similar to UFH and the LMWHs, fondaparinux should be used with extreme caution in patients with neuraxial anesthesia or following a spinal puncture owing to the risk for spinal or epidural hematoma formation. Unlike UFH and the LMWHs, fondaparinux does not cause heparin-induced thrombocytopenia and does not produce cross-sensitivity in vitro." A specific antidote to reverse the antithrombotic activity of fondaparinux is not currently available, but several potential products have been evaluated. 

Chan L, BaUin MT. Spinal epidural hematoma following central neuraxial blockade and subcutaneous enoxqxaiin a case report. J Clin Anesth (2004) 16,382-5. 

Litz RJ, Hubler M, Koch T, Albrecht DM. Spinal-epidural hematoma following epidural anesthesia in the presence of antiplatelet and heparin therapy. Anes tesiology (2001) 95,1031-3. 

Several cases of abnormal bleeding have been reported in association with garlic ingestion. These cases include spinal epidural hematoma with platelet dysfunction (Rose et al. 1990), post-operative bleeding (Burnham 1995 German et al. 1995) and a periorbital hematoma (Garden et al. 2002). 

Nervous system A spontaneous spinal epidural hematoma in a 62-year-old man taking aspirin 100 mg/day caused low back pain, progressive bilateral lower limb weakness and numbness, and urinary retention [63" ]. He subsequently developed paraplegia with a sensory level at LI, lax anal tone, and reduced perianal sensation. Emergency decompression laminectomy was followed by recovery. 

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