casos clinicos

Revista de la Sociedad Española del Dolor
versión impresa ISSN 1134-8046
Rev. Soc. Esp. Dolor v.11 n.7 Narón (La Coruña) oct.-nov. 2010
CASO CLÍNICO

Hematoma epidural secundario a anestesia espinal. Tratamiento conservador
M. Bermejo1, E. Castañón1, P. Fervienza1, F. Cosío1, M. Carpintero1 y M. L. Díaz-Fernández1


Bermejo M, Castañón E, Fervienza P, Cosío F, Carpintero M,Díaz-Fernández ML. Epidural hematoma secondary to spinal anesthesia.; 11: 452-455.


SUMMARY
Introduction:
Epidural hematoma secondary to neuroaxial anesthesia is a rare complication, but highly relevant due to its clinical and medico-legal implications. According to some authors, its incidence can reach 1/190,000-1/200,000 for peridural punctures and 1/320,000 for spinal punctures. Early diagnosis andtreatment within the first 6-12 hours is the main aspect related to its therapeutic management. However, in some cases such as the one reported here, surgery is not required and the patient can be managed with a conservative treatment.
Clinical case:
A 73-year-old patient, ASA IV, with a history of cirrhosis associated to portal hypertension, hypersplenism, COPD, obesity, hypertensive cardiopathyand tricuspid failure. He was scheduled for prostate alcoholization after ruling out surgery. Preoperative blood analyses showed a prothrombin activity of 80% and 90,000 platelets.
Several failed attempts of spinal puncture were done, but general anesthesia was finally required with spontaneous ventilation through laryngeal mudpack, propofol, fentanyl and sevoflurane.
Clinical manifestationsappeared after 36 hours, with non-irradiated severe lumbar pain and plantar cutaneous areflexia. The presence of epidural hematoma at the L1-L4 level was confirmed through NMR. Given the absence of flaccid paraparesis, sphincter involvement or other sensitive-motor signs and after consultation with the Rachis Unit and the Neurology Service, a conservative treatment and an expecting attitude wereagreed based on analgesia and strict neurological monitoring, both clinical and radiological. The evolution of the patient was favorable in the next days.
Discussion:
Certain clinical conditions can affect the appearance of hematoma after performing a central regional blockade: low molecular weight heparins, difficult punctures, previous vertebral surgery, hepatopathies, drugs, etc.
Earlysurgical treatment based on decompression laminectomy is usually required and it is the treatment agreed in many cases, but in some patients such as this one, with no compressive symptoms, no progression of symptoms or a rapid improvement of symptoms, a conservative treatment based on analgesia and corticotherapy can be decided, always with a strict control in order to allow a quick intervention ifthere is a negative event in the evolution of the patient. © 2004 Sociedad Española del Dolor. Published by Arán Ediciones, S.L.
Key words: Epidural hematoma. Spinal anesthesia. Conservative treatment.
 

RESUMEN
Introducción:
El hematoma epidural secundario a una anestesia neuroaxial es una complicación poco frecuente, pero de gran trascendencia tanto por sus implicaciones clínicas como porlas médico legales; según algunos autores su incidencia puede oscilar entre 1/190.000-1/200.000 para las punciones peridurales y 1/320.000 en el caso de las espinales. El aspecto prioritario en su manejo terapéutico es el del diagnóstico y tratamiento precoz, antes de las 6-12 primeras horas. No obstante, en determinados pacientes como en el caso que presentamos puede no ser precisa la cirugía,resolviéndose el cuadro con tratamiento conservador.
Caso clínico:
Varón de 73 años, ASA IV, con antecedentes de cirrosis con hipertensión portal, hiperesplenismo, EPOC, obesidad, cardiopatía hipertensiva e insuficiencia tricuspídea. Se programa para alcoholización prostática al haber sido desechada la cirugía. En la analítica preoperatoria destacaba una actividad de protrombina del 80% y 90.000...