Epidural: ASRA guidelines for anticoagulation

Which of the following statements is NOT true with regards to a neuraxial (spinal, subdural, or epidural) hematoma?

A. The most common presenting symptom of a neuraxial hematoma is back pain.
B. The risk of neuraxial hematoma development is greatest upon placement block and catheter removal.
C. Decompressive laminectomy is the treatment for neuraxial hematoma, and neurologic recovery is more likely when this is performed within 8 hours of symptom onset.
D. It is local anesthetic, not opioids, in the neuraxial space that results in motor/sensory changes, and local anesthetic infusions must be discontinued in order to properly assess for neurologic function if assessing for presence of epidural hematoma.

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Correct Answer: A

Explanation:

The most common presenting symptom of a neuraxial hematoma is motor changes. Radicular back pain may also occur, but as a presenting symptom, is not as frequent as motor changes. Sensory deficits is less frequently the presenting symptom than back pain and motor deficits. All the other statements are true. Decompressive laminectomy is the only way to definitively manage a neuraxial hematoma in a patient with motor changes, and surgery must be performed as early as possible to prevent irreversible ischemic damage. Retrospective review of cases noted that there appears to be an 8 hour window from symptom development to decompressive laminectomy in order to minimize chances of progressing to irreversible neurologic injury. It should be noted, however, that surgery within 8 hours of symptomatology does not guarantee a full neurologic recovery. Therefore, there must be a sense of urgency when assessing a patient with motor/sensory changes or radicular back pain after neuraxial block. Local anesthetics in the spinal or epidural space will mask these symptoms. Therefore, if the patient is at risk for spinal hematoma, neurologic assessment can be performed by discontinuing local anesthetic (and managing pain with neuraxial or systemic opioids) and observation for improvements in neurologic function.

References:

Vandermeulen Ep, Aken HV, Vermylen J. “Anticoagulants and Spinal-Epidural Anesthesia.” Anesth Analg 1994;79:1165-77.

Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW. “Injuries associated with Regional Anesthesia in the 1980s and 1990s.” Anesthesiology 2004;101:143-52.

Horlocker TT, Wedel DJ, Rowlingson JC, Enneking K, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010;35:64-101.

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