TITLE:
Epidural Hematoma after the Use of Subcutaneous Unfractionated Heparin and History of Epidural Tumor
AUTHORS:
Basem A. Abdelfattah, Troy Buck, Scott Byram
KEYWORDS:
Epidural Hematoma, Epidural Metastasis, Heparin
JOURNAL NAME:
Open Journal of Anesthesiology,
Vol.4 No.7,
July
21,
2014
ABSTRACT:
The patient was a 66-year-old male with a history of renal cell carcinoma
with metastasis to the L2, L3, and L4 vertebral bodies scheduled for a radical
nephrectomy and adrenalectomy. Prior to surgery the patient had undergone 10
radiation treatments for the vertebral metastasis. Patient medications included
colace, prednisone, ibuprofen (taken 4 days prior to procedure), sunitinib,
hydrocodone, benazepril, nexium, rosuvastatin, allopurinol, and azor. Physical
exam prior to surgery was normal with no focal findings. Laboratory values were
within normal limits with a platelet count of 286. General anesthesia was
planned with a pre-operative thoracic epidural for postoperative analgesia. The
epidural was placed at the T9-T10 level without complication. Adequate pain
control was present post operatively and the epidural was discontinued on
post-operative day 3. At that time the patient was noted to have numbness over
the bilateral lower extremities and decreased strength. Heparin 5000 units
subcutaneous had been given 12 hours prior to discontinuation of the epidural.
The patient was afebrile, hemoglobin was 7, white blood cell count was 9.7, and
platelets were 166 at time of epidural removal. Subcutaneous heparin was
restarted 6 hours after catheter removal. The anesthesia acute pain service was
contacted by the primary service 25 hours after discontinuation of the epidural
catheter regarding complaints of persistentbilateral
lower extremity weakness and sensory loss. An magnetic resonance image (MRI)
revealeda focus posterior to the spinal cord at the T10/T11 interspace
likely representing a hematoma. A high intensity T2 signal within the central
spinal cord at T10/T11 was also observed; likely a vascular infarct. The
patient was immediately scheduled for a T9-T10 laminectomy and evacuation of
the epidural hematoma. No significant abnormalities were noted in coagulation
studies prior to surgery. The patient was discharged on post-operative day 20
with no neurologic deficits.An epidural hematoma is rare with an estimated
occurrence of