Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome.

BACKGROUND: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. CASE DESCRIPTION: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit.
CONCLUSIONS: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.

INTRODUCTION

Post-traumatic, iatrogenic or spontaneous spinal hematomas (epidural and/or subdural) are rare and have different pathophysiological causes. Several factors contribute to the genesis of a spinal hematoma, such as vascular malformations, coagulopathies, thrombolytic drug administration, tumors, autoimmune diseases, pregnancy, excessive exercise, previous epidural anesthesia, cardiac surgery, and lumbar puncture.[245678101216181920222325282930333436] This type of lesion indiscriminately affects both sexes, all ethnicities, and all age groups.[131516172331] Clinical symptomatology varies from pain to sensory and/or motor deficits, hemiparesis, Brown-Séquard syndrome, incomplete or complete spinal cord syndrome, as well as cauda equina syndrome.[1124] Treatment may be conservative or surgical, depending on the clinical examination and imaging findings.

Here, we present a rare case of a large multicomponent, combined epidural and subdural spinal hematoma extending from the cervical spine to the low thoracic spine that was treated conservatively.

CASE DESCRIPTION

History

A 38-year-old woman who had recently undergone epidural spinal anesthesia for a caesarean section 4 days prior presented to the emergency department (ED) of our institute complaining of severe neck and low back pain. Postpartum, her postoperative course was complicated by dyspnea and chest pain that was found to be secondary to a new pulmonary embolism. During her initial hospitalization, she received antithrombotic therapy sustained by unfractionated heparin (with close monitoring of her clotting mechanism) and was bridged to warfarin therapy prior to her discharge to home. At the ED, she did not have any weakness, paresthesias, or changes in motor “function,” although she described some nonspecific back pain.

Examination

On examination in the ED, the patient had 5/5 strength in all muscle groups in the upper and lower extremities, no signs of sensory deficits, or signs of cauda equina syndrome, but she did have several beats of clonus in the lower extremities. Laboratory testing demonstrated only a mildly elevated international normalized ratio of 1.8, which was below the expected value. Magnetic resonance imaging (MRI) of the entire spine demonstrated a large amount of mixed epidural and subdural blood collection within the high thoracic and lumbar spine as well as cord edema near T6-7 [Figures 1–3]. The epidural component was located in the upper thoracic spine. Cervical MRI demonstrated pathology consistent with acute/subacute subdural hematoma in the cervical spine [Figure 4].

Figure 1

Thoracic magnetic resonance imaging (MRI), sagittal T2 sequence with contrast enhancement, showing extra-axial subdural abnormality involving the entirety of the thoracic spinal canal extending from the cervical to the lumbar spine (small arrows). Minor signal within the spinal cord parenchyma is most likely associated with edema (large arrow). These findings were consistent with extensive acute/subacute subdural–epidural hemorrhage

Figure 3

Lumbar MRI, axial T2 sequence without contrast enhancement, showing extensive extra-axial subdural abnormality (arrow) as described above. Findings were consistent with acute/subacute subdural hematoma

Figure 4

Cervical MRI, sagittal T2 sequence without contrast enhancement, showing an extensive extra-axial hematoma initiating from the prepontine premedullary cistern to the upper thoracic spine (left arrows). At the C6-C7 level, a pathological signal is noted within the spinal cord parenchyma with minor mass effect (right arrow)

Thoracic MRI, axial T2 sequence without contrast enhancement, showing extra-axial subdural abnormality (arrow)

Hospital course

After the diagnosis was made, the patient was admitted to the neurosurgical intensive care unit (neuroICU) for reversal of her mild coagulopathy (due to previous warfarin therapy) with the administration of fresh frozen plasma and vitamin K, as well as for pain control and surveillance. While in the neuroICU, she experienced an episode of tachycardia and shortness of breath for which she underwent thoracic computed tomographic angiography, which showed a small right basilar atelectasis. These symptoms were thought to be due to a transfusion reaction to the plasma and vitamin K. She was treated conservatively with pain control management and bedrest. After gradual mobilization, she was discharged without any neurological deficits or complications. Her atelectasis and pain were resolved; the hematoma had stabilized according to the last imaging study performed during her hospitalization. The last MRI study, obtained 9 months after her discharge, showed that the hematoma is slowly resolving. The patient is neurologically stable and is completely mobile, although she is still having episodes of low back pain and wears a brace for comfort.

DISCUSSION

Although many cases of spinal subdural or epidural hematomas have been described in the literature, this case is unique because it is a case of a mixed hematoma that was successfully managed conservatively. Although epidural anesthesia is a commonly used means of anesthesia, it can be associated with serious complications in 0.1–1 per 10000 epidural injections.[37] Anticoagulant therapies also have been linked to increasing the risk for spinal epidural hematomas.[3235]

The treatment of spinal subdural, epidural, or combination hematomas may be conservative or surgical, although the borders between these two options are sometimes subjective.[13142526] According to the literature, neurological outcome is favorable in patients with epidural spinal hematomas that are surgically evacuated within 72 h from symptoms onset.[2127] However, there are studies supporting the conservative management of spinal hematomas associated with coagulation disorders because the hematoma may expand in the epidural space without causing significant spinal cord pressure.[6] In these cases, there is always the risk of hematoma enlargement with subsequent significant neurological deterioration for the patients. Dziedzic et al.[9] showed that immediate surgical intervention for patients with neurological deficit could restore functionality. Further, these authors found that coagulation disorders were associated with poor neurological outcome. In our case, the hematoma was mixed (epidural–subdural). Our patient did not have any significant neurological deficit. We decided to follow a conservative course, with close follow up in the neuroICU and the administration of pharmaceutical agents, such as FFP and vitamin K that could correct her coagulation disorder. NeuroICU monitoring ensured reliable and hourly neurological assessments. As was reported by Walters et al.,[38] constant clinical evaluation of the patient and imaging surveillance such as MRI allow physicians to make decisions that ensure patient safety and functionality.

Given our patient's recovery, we believe that clinical examination findings should dictate the management for such patients. Imaging findings, such as size of the hematoma, should never be used as the only guide for treatment strategizing.[38]

Author contributions

Concept and design: Dimopoulos, Siasios; Acquisition of data: Siasios, Vakharia; Analysis and interpretation of data: all authors; Drafting the manuscript: Siasios, Vakharia; Critically revising the manuscript: all authors; Final approval of the manuscript: all authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.