Chapter 70

Intraspinal hematoma is a relatively rare condition resulting from a variety of causes. Its incidence is approximately 0.1 per 100,000 patients per year.1,2 Traumatic causes include lumbar puncture and neuraxial anesthesia as well as a complication of spinal surgery. It is more likely to occur in anticoagulated or thrombocytopenic patients, patients with neoplastic disease, or in those with liver disease or alcoholism.3,4 Spontaneous bleeding is rare but may be seen from a spinal arteriovenous malformation or vertebral hemangioma. Approximately one quarter to one third of all cases are associated with anticoagulation therapy.5,6

Hemorrhage into the spinal canal commonly occurs in the epidural space because of the presence of a prominent epidural plexus of veins. Puncture of epidural vessels during placement of epidural catheters occurs in approximately 3–12% of cases. The incidence of symptomatic epidural hematoma associated with epidural analgesia is difficult to estimate, but combined case series of more than 100,000 epidural anesthetics have been reported without a single epidural hematoma. Spinal hematoma is a rare but devastating event. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown; the incidence cited in the literature is estimated to be 1 in 150,000 epidural and 1 in 220,000 spinal anesthetics. However, the incidence increased significantly after the introduction of low-molecular-weight heparin (LMWH), before the Food and Drug Administration issued a warning, and before the American Society of Regional Anesthesia (ASRA) issued its initial consensus statement in 1998.7

The risk of formation of intraspinal hematoma after administration of neuraxial anesthesia and analgesia is increased in patients who received anticoagulant therapy or have a coagulation disorder.8 For that reason neuraxial anesthesia is often contraindicated in the presence of a coagulopathy. Other risk factors for development of epidural or spinal hematoma include technical difficulty (multiple attempts) in the performance of the neuraxial procedures due to anatomic abnormalities of the spine and multiple or bloody punctures. Intraspinal hematoma is more often associated with epidural catheter use than with the other neuraxial block techniques.

ASRA has recommended guidelines for the safer performance of neuraxial blocks in patients who are on anticoagulants.7,9 These guidelines were based on extensive review of the literature and of the pharmacology of the different anticoagulants. Recommendations were made on the timing of the neuraxial block and removal of the epidural catheter and the administration of the anticoagulants. In particular, the use of low concentrations of local anesthetics for epidural infusion (preservation of motor strength for easier monitoring) and subsequent neurologic monitoring were recommended by ASRA. The initial consensus guidelines, published in 1998 and updated in 2003,7,9 greatly assisted clinicians in decision making with regard to the use of neuraxial procedures in the setting of anticoagulation therapy and possibly decreased the incidence of epidural and spinal hematoma. In this chapter, we discuss the significance of ...

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