Dr.Sripali Dassanayake

Case report History

Mr.Kiriganitha

75 years

Warakapola

c/o sudden painful swelling of Right calf for 1 day

No history of recent trauma to leg

No history of fever

No history of injuries to LL or wounds

No evidence of filarasis

Admitted to BH warakapola on 13/01/2011

Transferred to TH Kegalle on 14/01/2011 admitted to

ETU at 4pm

Past medical historyno past history of bleeding disordersno history of haematological malignancies

Not a known diabetic(but on admission FBS was 180mg/dl)

No hypertension,CVA,TIA

No chest pain, no IHD,No exertional dyspnoea

Good exercise tolerance

Past surgical History

History of head injury following fallen from bicycle on ground 1 year back-scalp laceration sutured under LA-no intractable bleeding

Family history

No bleeding discrasia

Social history

A farmer, father of a daughter, living with daughter’s family

On Examination

Pt.In pain

GCS 15/15

Afebrile

not dyspnoeic

Mild pallor+

CVS-PR 80/min regular, good volume

BP-130/80mmHg

Heart in dual rhythm no murmurs

Capillary refilling time<2s

Respiratory –B/L equal breath sounds

Few fine crepts on bases

No rhonchi

Abdomen –soft

R/LL-swallen,erythematous calf which is tender and warm to touch

Investigations

Hb-10.7g/dl PCV-36%

WBC-10,800 N 67% L 28% M 5% E 2%

BT-3min CT-4min

Platelet count-307*1000/ul

BU-45 Na+138 K+3.8

ECG-no ischaemia

USS R/LL-?intra muscular collection of blood,no evidence of DVT

VS opinion to do urgent fasciotomy of R/LL for compartmental release

On 14/01/11 at 5pm Sub Arachnoid Block given(single attempt) under strict aseptic conditions under LA via a 25G pencil point spinal needle, Heavy Bupivacaine 2.3cc introduced intrathecally after observing a free flow of clear CSF.

Spinal level achieved-L1

Compartmental release done making 2 surgical incisions on either side of the R/LL. muscle haematoma found. clots removed. the exact bleeder not found. tight bandage applied.

Recovery uneventful.

Bleeding from wound site found in the night of the same day.

Re exploration done on the following day.15/01/2011 at 12.30pm after transfusion of 1U of blood.

Pre op BP-120/60mmHg PR-80/min

SAB given in 3rd attempt under absolute aseptic procedure under LA with Heavy Bupivacaine 1.8cc.

CSF was blood stained.?traumatic puncture

Clots were removed and haemostasis achieved. Pt. Kept in the recovery room for 10min.post op BP-100/60 mmHg ,no other complains and sent to the ward.

At 7.30pm,Pt.was complaining severe backache.

Managed as ?positional backache and had been given pain relief, not informed seniors ,were not suspicious about symptoms.

Following day Pt. complained of urine retention +weakness of B/L LL

O/E of LL

Tone

Power-Grade 1 (flicker of movements only)

Reflexes

Sensory level-mid thigh(L2)

Seen by CA- Spinal Haematoma need to be excluded .Need Urgent MRI

Urgent investigations sent .

Hb-8.3g/dl

BT-2 1/2min

CT-1 1/2min

Platelet count-312*1000

PT-12.6s

INR-1

VP informed-need urgent MRI to exclude spinal haematoma

Could not get the MRI done on the same day.

Neurosurgical opinion-to start on Methyl Prednisolone until MRI is available.

MRI on the following day (at Radiology Unit SBCH):MRI Thoraco-lumbar spine:-Subdural haematoma at L3-T12 with cord compression

Transferred to Neurosurgical unit Kandy Neurosurgical opinion-Ct. IV Methyl Prednisolone

No need of surgical evacuationConservative Mx only

Haematological referral to exclude; Acquired factor XIII deficiency Acquired VWD Acquired platelet dysfunction Acquired fibrinogen disorder

APTT-28s(normal)

Haematologist opinion to do 2nd line invetigations;

Thrombin time

Clot stabilizing time

D.D. ?Acquired factor XIII deficiency

?Acquired fibrinogendeficiency/dysfibrinogenemia

Pt, was started on Cryoprecipitate before completing Ix as oozing from wound site

GCS level + spastic paraplegia-CT brain:frontalischaemia + cerebral atrophy.......... ?stupor

Now-regain GCS with slight movements of LL, On physiotherapy......sensory level came down to below knee...

Causes for epidural haematoma

Predisposing factors:

Pre-existing coagulopathy

Spinal vascular malformation

Hypertension

Therapeutic thrombolysis

Use of antiplatelet or anticoagulant therapy

Administration of any kind of neuro-axial anaesthesia

Haemorrhagic complications after epidural anaesthesia- 1:150 000-1:190 000

After spinal anaesthesia- <1:220 000

Very infrequent complication but very serious consequences

permanent paraplegia

Reasons for epidural haematoma

Anatomical abnormalities

Eg:spinal haemangiomas,vascular lymphomas

Traumatic puncture with multiple attempts

Coagulation disorders( 54%) -2ndory to defect in haemostatic mechanism eg:Leukaemia,Haemophilia,Thrombocytopenia, cryoglobulinaemia,haemorrhagic diathesis, polycythaemia

Anticoagulant therapy(Acute or Chronic)(30%)

Among these newest anticoagulants - the very potent platelet aggregation inhibitors (e.g., ticlopidin),thrombin antagonists (e.g., melagatran), and factor Xa inhibitors (e.g., fondaparinux)

a) T1 scan revealing Isointense linear biconvex mass compressing on the lower thoracic spinal cord and cauda equina (arrow heads). (b) Same lesion showing heterogenous signal of hyperintensity (arrow heads) and hypointensity (arrow) on T2 scan

severe Lumbar pain(absence of pain does not exclude haematoma)

Motor impairment –flaccid paralysis (if cephaladmigration of haematoma occurs-spastic paralysis)

Sensory loss with sensory level below the level of compressed spinal segment

Sphincter disturbance-Urine retention

Surgical decompression by laminectomy is the definitive treatment

OUTCOME

1. Severity at presentation 2. Time from presentation to surgery

Onset of symptoms SurgeryWithin 12 hrs-60%recovery rate

>24 hrs-10% recovery rate>8hrs known to be associated with worse prognosis

Also if it is Sub Arachnoid HaemorrhageOr there were pre op neurological deficits

• Recognize symptoms

• Ix of choice-MRIEarly

diagnosis

• Urgent neurosurgical interventionAggressive

treatment

Detection and management of epidural haematomas related toanaesthesia in the UK: a national survey of current practice†

Protocol proposal

(i) Patients with epidural infusions running should have observations that include assessment of motor block made at least every 4 h.

(ii) These observations should continue for at least 24 h after removal of the epidural catheter.

(iii) There should be a designated person responsible for investigating signs suggestive of epidural haematoma.

(iv) If significant deterioration in motor function occurs in the absence of a recent bolus dose of local anaesthetic being administered, the designated person should be contacted immediately.

(v) If motor block is attributed to a recent bolus dose of epidural drugs, reassessment should occur within 2 h.

(vi) If an epidural infusion is running, it should be turned off, alternative analgesia instigated as necessary ,and a reassessment of the patient’s motor function should be made after a defined interval. The motor block would be expected to resolve if due to overdose or catheter migration. If motor power does not improve, remediable causes, including epidural haematoma or abscess, must be excluded.

(vii) Once an epidural haematoma is suspected, an MRI scan should be organized immediately, as this is a potential neurosurgical emergency. A protocol should be agreed in advance with the diagnostic imaging service.

(viii) If MRI scanning is not available in the local hospital or there will be a delay, then the patient should be referred to a neurosurgical unit to be scanned. It may be appropriate to arrange a protocol with local neurosurgical units to minimize delays in investigation and treatment.

Thank You !