Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 - 2015. Part 2: diagnosis, treatment, and outcome

Abstract

Background: Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs, neurological injury associated with SH has the worst prognosis. Around the turn of the millennium, the first guidelines aiming to reduce the risk of this complication were published. These guidelines are based on known risk factors for SH, rather than evidence from randomized, controlled trials (RCTs). RCTs, and hence meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing data from a significant number of published case reports of rare complications may reveal risk factors and patterns undetectable in reports on occasional cases, and can thereby help to improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015 with regard to diagnosis, treatment, and outcome of SH after CNB.

Methods: MEDLINE and EMBASE were utilized to find case reports published in English, German, or Scandinavian languages between 1994 and end of 2015, using appropriate search terms. Reference lists were also scrutinized for case reports. We documented initial and worst symptoms and signs of SH, diagnostic methods, treatment, and outcome of the SH. We calculated occurrences in per cent using the number of informative reports as denominator.

Results: One hundred and sixty-six case reports on spinal hematomas after CNB published during the years between 1994 and 2015 were identified. Eighty per cent of the patients had severe neurological symptoms (paresis or paralysis). When compared over time, outcomes have improved significantly. Among patients subjected to surgical evacuation of the hematoma, outcomes were best if surgery was performed within 12hours from the first sign of motor dysfunction. However, even patients operated after more than 24hours had relatively favourable outcomes. Whereas the outcomes after surgical evacuation of the epidural haematomas were quite satisfactory, only one of the operations for subdural haematoma (SSDH) resulted in a favourable outcome.

Conclusions and implications: Suspicion of a spinal hematoma calls for the consultation of an orthopaedic or neurological surgeon without delay. MRI is the recommended diagnostic tool. Surgical evacuation within 12h from the first sign of motor dysfunction seems to lead to the best outcome, although many patients operated as late as after more than 24hours did regain full motor function. Despite the poor prognosis after surgical evacuation of SSDH, the outcomes after post-CNB spinal haematoma in general have improved significantly over time.

Keywords: Anaesthesia; Complications; Haematoma; Neurological; Regional; Spinal.