Chapter 71

Spinal epidural hematoma (SEH) is an accumulation of blood in the potential space between the dura and the bone. Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. SEH may be spontaneous or may follow minor trauma, such as lumbar puncture or neuraxial anesthesia. It is more likely to occur in anticoagulated or thrombocytopenic patients, or in those with liver disease or alcoholism. Approximately one quarter to one third of all cases are associated with anticoagulation therapy.1,2 Spontaneous bleeding is rare but may be seen with anticoagulation, thrombolysis, blood dyscrasias, coagulopathies, thrombocytopenia, neoplasms, vascular malformations, or vertebral hemagioma.3,4 The peridural venous plexus is usually involved, though arterial sources of hemorrhage also occur.5 SEHs are mostly venous in nature because the venous plexus lacks valves, and the plexus has been shown to permit a reversal in blood flow during pressure increase from physical activity.6 Hematoma sites are usually found in the cervical and thoracic spine.7 Most SEHs are located dorsal to the dural sac because of the firm adherence of the dural sac to the posterior longitudinal ligament in the ventral aspect of the spinal canal. The dorsal aspect of the thoracic or lumbar region is involved commonly, and expansion is limited to a few vertebral levels.

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Clinical Pearls
 Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. SEH may be spontaneous or may follow minor trauma, such as lumbar puncture or neuraxial anesthesia. SEH occurs primarily in anticoagulated or thrombocytopenic patients. The risk of spinal hematoma in patients without overt risk factors is less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthesias.

### Incidence

SEH represents a rare spinal emergency, with a frequency of less than 1% of spinal space-occupying lesions.8 SEH affects 1 per 1,000,000 people annually.9,10 The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown. In an extensive review of the literature, the calculated incidence was approximated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthesias.11 No racial predilection has been reported, but SEH is more frequent in females. Increased age has been associated with more frequent SEH.

Anticoagulant therapy in association with neuraxial analgesia, as well as the length and intensity of anticoagulation, has been identified as one of the most important risk factors for epidural hematoma.12 Decreased weight and concomitant hepatic or renal disease, which may exaggerate the anticoagulant response, represent theoretical concerns for bleeding tendency. Thrombolytic therapy represents the greatest risk factor for bleeding complications.13

### History & Physical Examination

The patient is usually in significant distress and usually presents with ...

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