Spinal Subdural Hematoma following Epidural Anesthesia

Abstract

The spinal subdural space is an avascular, potential space and is a rare location for intraspinal hematomas. Compared to spinal epidural hematomas, spinal subdural hematomas are uncommonly described complications of lumbar puncture for spinal or epidural anesthesia, particularly in patients who have no pre-existing bleeding disorders or history of antiplatelet or anticoagulant intake. We describe a 19-year-old girl who had a large thoracolumbar spinal subdural hematoma following epidural anesthesia for elective cholecystectomy with no pre-existing bleeding diathesis that caused rapidly developing paraplegia that evolved over the next 2 days following surgery. Nine days after the initial surgery she underwent multilevel laminectomy and surgical evacuation with eventual satisfactory recovery. Even epidural anesthesia without thecal sac violation can result in bleeding in the spinal subdural space. The possible sources of bleed in this space may be from injury to an interdural vein or extravasation of subarachnoid bleed into the subdural space. When neurological deficits occur, prompt imaging is mandatory and early evacuation yields gratifying results.

Keywords: complications; epidural anesthesia; laminectomy; lumbar puncture; spinal subdural hematoma.

Fig. 1

T2 sagittal magnetic resonance imaging ( A ) showing a heterogeneous intensity mass situated anterior to the spinal cords and roots with signal change in the cord at D10-D12 levels. The mass is predominantly hyperintense and anteriorly located on T1 imaging both at dorsal ( B ) and lumbar ( C ) levels ( green arrows ). Axial T2 image at D12-L1 level ( D ) shows a hypointense lesion compressing cord and roots with obliteration of the cerebrospinal fluid (CSF) space, axial T1 image ( E ) shows the “cap” sign with cord pushed dorsally ( orange arrow ), and axial T1 image at the lumbar spine ( F ) too shows hyperintense lesion ( orange arrow ) with effacement of CSF space and root compression.

Fig. 2

Intraoperative microscopic images showing ( A ) organized thick clot anterior to the roots in the lumbar region, ( B ) piecemeal removal of clots with exposure of anterior dura, in the dorsal region the clots are drawn into the limited operative field by gentle suction ( C ) and then removed with forceps ( D ), clean anterior dura ( E ) is seen and finally ( F ) cord with normal vasculature after clot removal. All images show neither the cord nor the roots to be stained with blood showing it is not subarachnoid in location.

Fig. 3

Postoperative T2 sagittal magnetic resonance imaging ( A ) showing no residual clot and reformation of the cerebrospinal fluid (CSF) space around the cord and roots, sagittal T1 image ( B ) showing no residual hyperintense lesion, and T2 axial images at dorsal ( C ) and lumbar ( D ) levels showing cord and roots surrounded by CSF.