Anesthesia Toolbox Question:

You are called to evaluate a G4P4 admitted to the floor 5 hours ago after cesarean section under epidural anesthesia. The ICU nurse says the patient is still having difficulties feeling and moving her lower extremities. Your exam confirms the same. It is noted in the chart the epidural was removed at the end of the case in the operating room before transfer to the floor. You obtain an MRI of the lumbar spine which demonstrates spinal cord compression secondary to an epidural hematoma. Which of the following is the BEST management to optimize neurologic outcomes?

A.  Emergency surgery within 1-2 hours. ✔

B.  Urgent surgery within 6-8 hours.X

C.  Watchful waiting, if no improvement in 12 hours proceed to surgery. X

Read the discussion and key information below.

Discussion:

Epidural hematomas are rare in the obstetrics population for various theorized reasons but nonetheless are potentially devastating. Animal models demonstrate the degree of injury is related to the force and duration of compression on neural elements. Human studies have been conflicting, but the general belief is that duration of compression is important. Case series indicate that surgical decompression within 6 hours of symptom onset is associated with better outcomes and this is the most common recommendation for the timing of surgery in patients with neurological deficits. Case series have also indicated improved outcomes with surgery within 12 hours of the onset of symptoms. Since adverse neurologic outcomes are related to the duration of symptoms, prompt evaluation is key to facilitate surgical decompression ideally within 6-8 hours of symptom onset and not longer than 12 hours. In this patient the onset of symptoms is difficult to determine because of the resolution of the epidural anesthetic but could have been 5 hours ago; therefore, emergent surgery is indicated.

Key Information:

Epidural hematomas are rare events in the obstetric population. Adverse neurologic outcomes are related to the duration of symptoms; prompt evaluation is key to facilitate surgical decompression within 6-8 hours of symptom onset.

References:

Kreppel D, et al. Spinal hematoma: a literature review and meta-analysis 0f 613 patients. Neurosurg Rev. 2003;26: 1-49. PMID 12520314

Lawton M, et al. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg, 1995;83:1-7. PMID 7782824

Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R. Neuraxial anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low-molecular-weight heparin: a systematic review of spinal epidural hematoma. Anesth Analg. 2017;125(1):223-231. PMID 28628578

Wong CA. Nerve injuries after neuraxial anaesthesia and their medicolegal implications. Best Pract Res Clin Obstet Gynaecol. 2010;24(3):367-381. PMID 20053587

Al-mutair A, Bednar D. Spinal epidural hematoma. J Am Acad Orthop Surg. 2010;18(8):494-502. PMID 20675642

RAP Lecture 7 Complications of Neuraxial Anesthesia