Spontaneous spinal epidural hematoma after labour with epidural anaesthesia: a case report

Background: Spinal epidural hematomas are extremely rare, 0,1%/100,000 counting spontaneous and those associated with anaesthetic procedures1. During pregnancy the pressure in the abdomen and venous plexus, making them more susceptible to rupture and bleeding2.Case report: We report a 39y.o. full term secundipara woman with medical history of hypothyroidism and chronic neck pain. She received a L3-L4 lumbar epidural without incidents for labour according to our department protocol and 11h later went to c-section for cephalopelvic disproportion, with mild bleeding requiring oxytocin 10UI and methylergometrine 100mcg, being discharge from PACU 6h after surgery. 27 hours after the initial sitting of the epidural the patient developed acute intense posterior neck pain followed respiratory distress and progressive tetraparesis. The patient was transferred to the ICU and intubated due to respiratory arrest. Brain CT-scan was normal and the patient was awakened, her consciousness was intact but she had left sided hemiparesis. Brain and cervical MRI showed an anterior epidural hematoma in C5-C6 and decompression surgery was performed immediately. After the surgery the patient was transferred to the neurology unit for recovery and discharged home with a mild 4/5 left sided hemiparesis which still remains to date and chronic neck pain requiring amitriptyline, escitalopram and NSAIDs.Discussion: Spontaneous spinal epidural hematomas are extremely rare and there are only a handful of cases associated with pregnancy3. After reviewing the literature, we couldnu00b4t find any relationship to the initially sited epidural catheter, and the most probable cause was an arteriovenous malformation presenting with typical symptoms corresponding to the level of the hematoma in the spinal column. A fast diagnosis and management allowed the patient to recover fast and have minimal neurological damage.References1.tHirotaka I et al, A Case Report with a Literature Review of 50 Cases. Intern Med 2014;53: 57-622.tBose S et al, Spontaneuos spinal epidural hematoma. BJA 2007; 99:855-73.tPuah KL et al. Spontaneous cervical spine epidural hematoma in the postpartum period. Spine 2012;37:408-10Learning points: No all haematomas are related to anaesthetic techniques, even if the two events occur within a short time frame. Pregnancy is a characteristic physiological state predisposing so a wide range of pathologies and anaesthesiologist must be trained to promptly identify and manage them.