Journal: Anaesthesia 63(4):423-427, 2008
Reprint: Anaesthetic Registrar, Box Hill Hospital, Victoria, Australia (Dr DH Lam)
Faculty Disclosure: Abstracted by R. Ouellette, who has nothing to disclose.
Subarachnoid hematoma is a rare complication after spinal anesthesia and can lead to severe neurological impairment. In the majority of cases reported, spinal anesthesia had been difficult and unsuccessful. It has been reported to be associated with coagulation deficits, antiplatelet and anticoagulant therapy as well as direct spinal cord trauma. The clinical presentation commonly includes lower limb weakness, pain and sensory loss. Transient radicular irritation (TRI), also known as transient neurologic symptoms (TNS), has been described after spinal anesthesia. It is charac¬terized by pain or sensory abnormalities in the buttocks, lower back or lower limb without motor deficits, and can persist for several days after the effects of spinal anesthesia have subsided.
A case report was made of an elderly male patient who presented for elective, open inguinal hernia repair. For this operation, spinal anesthesia was requested by the patient because of a previous episode of emergence delirium after general anes¬thesia. Spinal anesthesia was initially attempted in the right lateral position. After two attempts in the right lateral position, a further attempt with the patient sitting was successful with good CSF flow; there were no paresthesias reported or blood obtained in all three attempts. The patient returned to the unit pain-free after 30 min in the recovery room with a residual motor and sensory block. On the unit he received 5000 IU of dalteparin subcutaneously for deep vein thrombosis prophylaxis 12 hours after the spinal injection. He was discharged home the next day. On the 5th day postoperatively he presented to the emergency department with lower back pain, buttock pain, and 'pins and needles' sensation in the right leg. These symptoms started on the second postoperative day and gradually worsened. A diagnosis of TRI was made and the patient discharged to be reviewed as an outpatient by a neurologist. The pain continued and on the 12th postoperative day he was re-examined and an MRI scanning was performed. The scan revealed a 4x1.3 cm subarachnoid hematoma at L3-L4. A neuro¬surgeon was consulted who advised conservative management. Over the next 6 days his symptoms improved with oral analgesics. Follow-up at 2 months revealed no residual symptoms and return to full function.
Spinal hematomas are rare; they can be epidural, subdural, or subarachnoid. In a review of 613 spinal hematomas, epidural hematomas accounted for 74% of all hematomas, 16% were subarachnoid, and the remainder were subdural or mixed. A large propor¬tion of cases of spinal subarachnoid hematoma occur after attempted spinal anesthesia when CSF was never obtained. Therefore, all attempts at spinal anesthesia should be well documented, even if unsuccessful. Symptoms can range from back pain, mimic TRI, to cauda equina syndrome and para¬paresis. Patients who develop symptoms and signs after anticoagulation therapy should be promptly investigated. MRI is the diagnostic test of choice, and emergency laminectomy is required if there are progressive neurological deficits. Conservative man¬agement may be appropriate in certain cases. Clinicians should be aware of this condition as delayed diagnosis can lead to disastrous outcomes. |
