Spinal epidural hematoma after lumbar catheter insertion in a patient who underwent TEVAR for an aneurysm of the descending aorta

Abstract

We present a case of spinal epidural hematoma after Lumbar catheter insertion in a patient who underwent TEVAR for an aneurysm of the descending aorta. Spinal epidural hematoma (SEH) is a relatively rare entity and has been reported to occur in patients who receive anti-coagulant therapy, have bleeding disorders, or after traumatic needle insertion. In our case, the epidural hematoma occurred 4 hours after catheter insertion, in a patient who received anticoagulant and antiplatelet medication. In these cases, early detection of symptoms and rapid diagnosis are an imperative. Our patient’s diagnosis was done 5 hours after symptom development and it consisted of thoracolumbar MRI that showed a spinal hyper-acute epidural hematoma extending from T9-T10 to L4-L5 and the affected segments of the spinal cord and conus medullar showed edema, most significantly at L1-L2 levels. A neurosurgical consult was done immediately after obtaining the results and within six hours after neurosurgical symptoms occurred, the patient underwent spinal decompression, the hematoma was evacuated and the patient regained motor function in her legs. During her stay at the cardiac ICU, the doctors administrated to our patient antiplatelet medication alongside low-molecular-weight heparin (LMWH)–inj. Clexane 40 I.U., against our recommendations. Due to this, our patient developed re-bleeding and we had to perform a second surgery, to do a more extensive spinal decompression and to evacuate the hematoma. Neurologic rehabilitation after the second surgery was difficult, but with extensive physical therapy, we have managed to achieve some improvement, with motor response 2\5 on the left leg and 3\5 on the right leg. Although anticoagulants and\or antiplatelet medication are a must in endovascular procedures and are considered safe to use during epidural analgesia, special attention and care to epidural hematoma should be given, especially in cases when an epidural catheter placement is needed.