Delayed postoperative spinal epidural hematoma
Neurosurgery Department, University General Hospital of Alicante, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Alicante, Spain
Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves 2).
Awad et al. 3) divided potential risk factors into two categories, preoperative and intraoperative factors. Significant preoperative risk factors included nonsteroidal antiinflammatory drug use and patient age more than 60 years; significant intraoperative risk factors included multiple-level operation, anemia, and large blood loss. Sokolowski et al. 4) reported that age greater than 60 years, multilevel procedures, and preoperative international normalized ratio (INR) correlated with postoperative hematoma volumes.
Parthibian and Majeed described a case which developed following an episode of violent twisting movement 5).
Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 6).
Surgical evacuation if symptomatic.
The administration of prothrombin complex concentrate (PCC) facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation 8).
Sokolowski et al. reported four cases of delayed symptomatic epidural hematoma without coagulopathy. In these cases, though, the initial symptoms included severe pain and muscle weakness at the level of previous surgery, the same symptom pattern that accompanies hematomas occurring shortly after surgery 9).
Uribe et al. report a series of delayed epidural hematomas in a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after their index procedure.
They reviewed the database of six spine surgeons over a 4-year period, looking for presence of epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days, and identified a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after spinal surgery.
Of 4,018 patients, they identified seven with spinal epidural hematoma who presented more than 3 days after their index procedure. The initial presenting symptom, which heralded the subsequent onset of neurological deterioration, consisted of severe sharp pain with radiation to the extremities. The average time to neurological deterioration was 5.3 days. Fifty-seven percent of the patients had multiple previous spinal surgeries at the site of the epidural hematoma. Surgical evacuation of the epidural hematomas resulted in neurological improvement in five patients. Persistent neurological deficits were observed in two patients.
Delayed spinal epidural hematomas are an uncommon cause of delayed deterioration after spinal surgery. Previous surgery with attendant scarring that results in impairment of clot resorption may be a contributing factor in the development of the condition 10).
A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved 11).
An 86-year-old woman was scheduled to undergo aortic valve replacement and coronary artery bypass graft. On postoperative day 3, she developed sudden-onset neck pain followed by weakness in the right arm. Her symptoms worsened with time, and she developed paraplegia. At 60 h after the first complaint, spontaneous spinal epidural hematoma (SSEH) from C2 to C6 with spinal cord compression was diagnosed from a magnetic resonance image of the cervical region. We decided on conservative therapy because operative recovery was impossible. Delayed diagnosis led to grievous results in the present case. When neurological abnormalities follow neck or back pain after open heart surgery, SSEH must be considered in the differential diagnosis. Further, if it is suspected, early cervical computed tomography/magnetic resonance imaging and surgery should be considered 12).
A rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered 13).
Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesia 14).
A patient 9 days after he underwent laminoplasty. The authors draw attention to the possibility of delayed PSEH and its triggering mechanism. In this case, a 59-year-old man with no history of bleeding disorder underwent cervical laminoplasty for mild myelopathy. On the 7th postoperative day computed tomography demonstrated no abnormal findings in the operative field. On the 9th postoperative day, while straining to defecate, the patient suddenly felt neck and shoulder pain, and tetraplegia rapidly developed. Magnetic resonance imaging demonstrated a huge epidural hematoma. The clot was evacuated during emergency revision surgery, during which the arterial bleeding from a split muscle wall was confirmed. The postoperative course after the revision surgery was uneventful and the patient had none of the previous symptoms 1 year later. A PSEH causing paralysis can occur even more than a week after surgery. The possibility of a delayed-onset PSEH should be kept in mind, and prompt diagnosis should be made when a patient presents with paresis or paralysis after an operation. The authors recommend advising patients that for a while after surgery they avoid strenuous activity 15)
Treatment of thromboembolic disease in the postoperative lumbar spine patient is controversial. This case report describes an epidural hematoma with neurologic sequelae in an elderly patient who received intravenous heparin therapy over 2 weeks after lumbar decompression 16)