Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942011000200011
Brazilian Journal of Anesthesiology
Clinical Information

Hematoma neuroaxial após bloqueio peridural. É possível prevenir ou detectar? Relato de dois casos

Neuraxial hematoma after epidural anesthesia. Is it possible to prevent or detect it? Report of two cases

Rodrigo de Lima e Souza; Luiz Otávio Fernandes Andrade; Joaquim Belchior Silva; Luiz Antônio Carneiro da Silva

http://dx.doi.org/10.1590/S0034-70942011000200011 Braz J Anesthesiol, vol.61, n2, p.221-224, 2011
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Resumo

JUSTIFICATIVA E OBJETIVOS: Os hematomas espinais são raros e acometem o sistema nervoso central. Podem causar sequelas neurológicas permanentes e morte se não tratados adequadamente. O diagnóstico e tratamento precoces são fundamentais para o bom prognóstico neurológico. O objetivo deste trabalho foi despertar no anestesiologista maior sensibilidade para o diagnóstico e o tratamento precoces dos hematomas espinais, além de aperfeiçoar sua prevenção. RELATO DOS CASOS: Caso 1: Paciente submetido à anestesia peridural lombar para a realização de revascularização fêmuro-poplítea. Estava em uso de ácido acetilsalicílico, clopidogrel e enoxaparina, medicamentos suspensos antes da operação. O paciente evoluiu com paraplegia no pós-operatório imediato. Realizou-se descompressão neurocirúrgica após o diagnóstico, porém sem recuperação do quadro em longo prazo. Caso 2: Paciente submetido à anestesia peridural lombar para osteotomia em joelho direito, sem intercorrências. O paciente permaneceu sem queixas neurológicas até aproximadamente 48 horas, quando iniciou quadro de retenção urinária, dor em membro inferior direito, parestesias e dificuldade de movimentação dos pés. Foi feita ressonância nuclear magnética, a qual evidenciou hematoma peridural lombar, sendo realizada a descompressão cirúrgica imediata. Após 10 meses de reabilitação, houve recuperação neurológica completa. CONCLUSÕES: Os casos clínicos apresentados mostraram desfechos diferentes, destacando a importância do diagnóstico e do tratamento precoces para a boa evolução do quadro clínico. O diagnóstico pela ressonância nuclear magnética, com a descompressão precoce logo após as primeiras manifestações clínicas, permanece como tratamento padrão. A identificação dos pacientes de risco para sangramentos neuroaxiais, a mudança de técnica anestésica, assim como o estabelecimento de protocolos de avaliação neurológica pós-operatória nos pacientes submetidos aos bloqueios de neuroeixo, podem contribuir para a prevenção de sequelas neurológicas graves.

Palavras-chave

COMPLICAÇÕES, COMPLICAÇÕES, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Spinal hematomas are rare and they affect the central nervous system. They can cause permanent neurologic sequelae and death if they are not treated properly. Early diagnosis and treatment are fundamental for a good neurologic prognostic. The objective of this report was to emphasize for anesthesiologists the importance of early diagnosis and treatment of spinal hematomas, besides improving their prevention. CASE REPORTS: Case 1: The patient underwent epidural lumbar anesthesia for femoropopliteal revascularization. He was being treated with acetylsalicylic acid, clopidogrel, and enoxaparin, which were discontinued before the surgery. The patient developed paraplegia in the immediate postoperative period. Neurosurgical decompression was performed after the diagnosis, but without recovery in the long run. Case 2: The patient underwent epidural lumbar anesthesia for right knee osteotomy, without intercurrences. The patient remained without neurological complaints until approximately 48 hours after the surgery when he developed urinary retention, pain in the right lower limb, paresthesias, and difficulty moving both feet. The MRI showed an epidural lumbar hematoma, and the patient underwent immediate surgical decompression. He showed complete neurological recovery after 10 months of rehabilitation. CONCLUSIONS: The clinical cases presented here showed different outcomes, indicating the importance of early diagnosis and treatment for a good evolution. Diagnosis by MRI with early decompression shortly after the development of the first clinical manifestations remains the standard treatment. Identification of patients at risk for neuraxial bleeding and change in anesthetic technique, as well as the establishment of postoperative neurologic evaluation protocols in patients undergoing neuraxial anesthesia can contribute for prevention of severe neurologic sequelae.

Keywords

Hematoma, epidural, spinal, Anesthesia, Epidural, Postoperative complications

References

Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology. 2004;101:950-959.

Ruppen W, Derry S, McQuay H. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology. 2006;105:394-399.

Brull R, McCartney CJL, Chan VWS. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg. 2007;104:965-974.

Moen V, Irestedt L. Neurological complications following central neuraxial blockades in obstetrics. Curr Opin Anaesthesiol. 2008;21:275-280.

Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev. 2003;26:1-49.

Groen RJM. Non-operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases. Acta Neurochir. 2004;146:103-110.

Meikle J, Bird S, Nightingale JJ. Detection and management of epidural haematomas related to anaesthesia in the UK: a national survey of current practice. Br J Anaesth. 2008;101:400-404.

Horlocker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res. 2001;101:V141-154.

Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg. 2009;109:648-660.

SreeHarsha CK, Rajasekaran S, Dhanasekararaja P. Spontaneous complete recovery of paraplegia caused by epidural hematoma complicating epidural anesthesia: a case report and review of literature. Spinal Cord. 2006;44:514-517.

Liguori GA. Complications of regional anesthesia. J Neurosurg Anesthesiol. 2004;16:84-86.

Seze MP, Sztark F, Janvier G. Severe and long-lasting complications of the nerve root and spinal cord after central neuraxial blockade. Anesth Analg. 2007;104:975-979.

Rocchi R, Lombardi C, Marradi L. Intracranial and intraspinal hemorrhage following spinal anesthesia. Neurol Sci. 2009;30:393-396.

Cameron CM, Scott DA, McDonald WM. A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital. Anesthesiology. 2007;106:997-1002.

Lee LA, Posner KL, Domino KB. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claim analysis. Anesthesiology. 2004;101:143-152.

Mendes FF, Luft A, Gomes LC. Déficit neurológico após bloqueio espinhal: Relato de caso. Rev Bras Anestesiol. 1999;49:38-39.

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