Thoracic epidural haematoma following epidural anesthesia

Clinical History

Development of paraplegy and urinary and faecal incontinence following operation for abdominal aortic aneurism.

Imaging Findings

The patient was operated for an abdominal aortic aneurism. Before induction of general anesthesia an epidural catheter was placed at the Th7-8 level. During surgery an endovascular prosthesis was placed in the abdominal aorta. One week postoperative the patient experienced a gradual loss of sensitivity and motor function of the lower exterimities. Initially the symptoms were mild. 6 days following the debut, the symptoms quickly worsened and now included complete paraplegy and faecal and urinary incontinence. The patient then underwent a magnetic resonance scan for the evaluation of the thoracic spinal cord. The scan was conducted 13 days after the operation and showed an epidural process from the lower part of the 7th thoracic vertebral body stretching down behind the 8th vertebral body. On the T1 weighted sequence the process was hyperintense in the periphery with a central hypointense area. From top to bottom the process measured 3 cm (figure 1). The spinal cord was compressed by the process as shown on the T2 weighted sequence (figure 2). Due to the endovascular aortic prosthesis the scanning contained some artifacts. Following the magnetic resonance scan the patient underwent laminectomy and the epidural process was shown to be a haematoma. This was removed. Renewed magnetic resonance scan one and a half month following surgery showed complete regression of the haematoma (figure 3). At that time the patient had regained faecal and urinary continence but the paraplegy persisted.

Discussion

The formation of an epidural haematoma is a very rare complication to epidural anesthesia with the incidence belived to be 1:150000 [1]. A number of case reports documents epidural haematomas following epidural anesthesia [2, 3, 4, 5]. Risk factors for epidural haematomas include anticoagulation therapy and coagulation disorders [6]. Cirrhosis of the liver with impaired production of coagulation factors is also a known risk factor [4]. Deformation of the vertebral column and vascular malformations may enhance the risk for epidural bleeding [6,7]. The use of a thoracic epidural catheter does not seem to be less safe than a lumbar epidural approach [8]. Immediate surgery with removal of an epidural haematoma is important as soon as the diagnosis is established. The most favourable outcome seems to occur in patients,that undergoes laminectomy with the removal of the epidural haematoma less than 8 hours of diagnosis [6,7]. In the present case the patient did not receive any anticoagulation therapy at the time of surgery and had no liver or coagulation disorder. Laminectomy was performed 24 hours following the diagnosis. The bad outcome with persisting paraplegy could maybe have been avoided, if the patient had been operated immediately following the diagnosis. The patient did not undergo magnetic resonance examination immediatly following the debut of the neurological symptoms. The reason for the scan being performed 6 days after the debut of the symptoms, was the fast progression of the neurological symptoms with paraplegy and incontinence this day. As epidural haematomas is a known complication following epidural anesthesia develpment of neurological symptoms after the procedure should lead to evaluation of the patients spinal cord with a magnetic resonance scan without any significant delay. In the present case a earlier magnetic resonance scan, when the symptoms were mild, could maybe have led to faster treatment and probably a better outcome.

Differential Diagnosis List

Final Diagnosis

Thoracic epidural haematoma

URL:	https://www.eurorad.org/case/5577
DOI:	10.1594/EURORAD/CASE.5577
ISSN:	1563-4086