Reducing risk of spinal haematoma from spinal and epidural pain procedures

Literature review of spinal hematoma case reports: causes and outcomes in pediatric, obstetric, neuraxial and pain medicine cases

BACKGROUND

The risk of spinal epidural hematoma (SEH) has been described in the literature but the impact in various patient populations has not been assessed in the same study. We identified the risk factors for SEH and calculated the OR for recovery in the pediatric, adult and obstetric (OB) patients based on the degree of neurological deficit before surgery.

METHODS

Adult non-OB cases were categorized whether they were on anticoagulants or not; SEH was related to neuraxial or pain procedure; or whether there was adherence to the American Society of Regional Anesthesia (ASRA) guidelines. Eligible cases were identified through PubMed and Embase searches in the English literature from 1954 to July 2022.

RESULTS

A total of 940 cases were evaluated. In the pediatric cases, SEH was typically spontaneous, related to coagulopathy or athletic trauma. OB cases were spontaneous or related to neuraxial injections. Among adults on anticoagulant(s), SEH was mostly spontaneous with no related etiology or related to neuraxial procedure. SEH occurred despite adherence to the ASRA guidelines. Among non-OB adults not on anticoagulants, SEH was due to trauma, neuraxial injections, surgery or other causes. Neurological recovery was related to the degree of neurological deficit before surgery.

CONCLUSIONS

Our data show a preponderance of spontaneous SEH in all patient populations. SEH developed even though the ASRA guidelines were followed, especially in patients on multiple anticoagulants. Patients with less impairment prior to surgery had a higher likelihood of complete recovery, regardless of the interval between surgery and onset of symptoms.

Spinal Cord Injury and Complications Related to Neuraxial Anaesthesia Procedures: A Systematic Review

The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to anaesthetic practice (Anaes-SCI) are rare events but remain a significant concern for many patients undergoing surgery. This systematic review aimed to identify high-risk patients summarise the causes, consequences, and management/recommendations of SCI due to neuraxial techniques in anaesthesia. A comprehensive search of the literature was conducted in accordance with Cochrane recommendations, and inclusion criteria were applied to identify relevant studies. From the 384 studies initially screened, 31 were critically appraised, and the data were extracted and analysed. The results of this review suggest that the main risk factors reported were extremes of age, obesity, and diabetes. Anaes-SCI was reported as a consequence of hematoma, trauma, abscess, ischemia, and infarction, among others. As a result, mainly motor deficits, sensory loss, and pain were reported. Many authors reported delayed treatments to resolve Anaes-SCI. Despite the potential complications, neuraxial techniques are still one of the best options for opioid-sparing pain prevention and management, reducing patients' morbidity, improving outcomes, reducing the length of hospital stay, and pain chronification, with a consequent economic benefit. The main findings of this review highlight the importance of careful patient management and close monitoring during neuraxial anaesthesia procedures to minimise the risk of spinal cord injury and complications.

Acute thrombocytopenia during cesarean section

We report a case of a healthy 29-year-old parturient with a normal pre-operative platelet count who received combined spinal-epidural anesthesia for cesarean section, and who suffered the sudden intra-operative onset of severe thrombocytopenia (platelet count 3 × 10⁹/L). This event was likely due to cefoxitin administered for the prophylaxis of surgical infection.

Evaluating the incidence of spinal cord injury after spinal cord stimulator implant: an updated retrospective review

INTRODUCTION

While spinal cord stimulator implant is an increasingly safe procedure, one of the most feared complications is spinal cord injury. Still, literature regarding its incidence remains highly variable. This retrospective analysis aims to evaluate the incidence of spinal cord injury after spinal cord stimulator implant using a large-scale claims database.

METHODS

The PearlDiver-Mariner database of national all payer claims was used to identify patients who underwent spinal cord stimulator implant (percutaneous or paddle) and developed subsequent spinal cord injury within 45 days. The primary outcome was to determine the overall incidence of spinal cord injury after spinal cord stimulator implant. Secondary outcomes included an evaluation of potential factors associated with developing spinal cord injury using univariable and multivariable regression analysis.

RESULTS

A total of 71,172 patients who underwent a spinal cord stimulator implant were included in the analysis, of which 52,070 underwent percutaneous and 19,102 underwent paddle spinal cord stimulator lead implant. The overall incidence of spinal cord injury after spinal cord stimulator implant (any lead type) was found to be 0.42% (302 patients). The incidence of spinal cord injury after percutaneous and paddle lead implants did not differ at 0.45% (233 patients) and 0.36% (69 patients)(p=0.12), respectively. Overall, variables associated with a significantly increased OR (95% confidence interval) of developing spinal cord injury included male gender by 1.31 times (1.04 to 1.65)(p=0.02); having a claim for low molecular weight heparin within 30 days by 3.99 times (1.47 to 10.82)(p<0.01); a diagnosis for osteoporosis within 1 year by 1.75 times (1.15 to 2.66)(p<0.01); and a diagnosis of cervical or thoracic spinal canal stenosis within 1 year by 1.99 (1.37 to 2.90)(p<0.001) and 4.00 (2.63 to 6.09)(p<0.0001) times, respectively.

CONCLUSIONS

Overall, our results support the notion that spinal cord stimulator implant continues to be a safe procedure for chronic pain patients. However, risk factor mitigation strategies for the prevention of spinal cord injury after spinal cord stimulator implant should be undertaken prior to performing the procedure.

Spontaneous Coronary Artery Dissection: Rediscovering an Old Cause of Myocardial Infarction

Spontaneous coronary artery dissection is an uncommon, but not insignificant cause of acute coronary syndrome that overwhelmingly affects middle-aged women. The pathophysiology of coronary dissection appears to be an outside-in mechanism, where the initiating event is not an intimal tear but rather the formation of an intramural hematoma, which compromises blood flow by reducing the arterial lumen. Considering this mechanism, it is clear to see how intracoronary imaging techniques, such as optical coherence tomography and intravascular ultrasound, are most accurate in the diagnosis. However, they carry a high rate of complications and are therefore generally avoided when the clinical scenario and angiographic appearance both support the diagnosis of spontaneous coronary artery dissection. The natural history of the disease is toward healing of the vessel wall and restoration of blood flow. Therefore, conservative medical management is the preferred approach unless there are high-risk factors such as hemodynamic instability, signs of ischemia and severe proximal or multivessel lesions, in which percutaneous or surgical revascularization should be considered. Perioperative evaluation of these patients must take into account several aspects of this disease. Most of these patients will be receiving single or dual antiplatelet therapy, so one must consider the timing of the event and the surgical hemorrhagic risk when deciding to stop these therapies. Extracoronary vascular disease also must be assessed because it can have an effect on patient monitoring and risk of postoperative complications.

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines

BACKGROUND

Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia.

DESIGN

A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline.

RESULTS

Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%.

DISCUSSION

Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply.

CONCLUSION

In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review

Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.

Ultrasound-guided quadratus lumborum block for postoperative analgesia: A systematic review and meta-analysis

BACKGROUND

Ultrasound-guided quadratus lumborum block (QLB) is a truncal block with several technique variations. It has been reported as providing effective analgesia for postoperative pain.

OBJECTIVES

The aim of this review was to evaluate the efficacy and safety of QLB for postoperative analgesia. The primary outcome was cumulative opioid consumption at 24 h postoperatively. The main secondary outcomes were the time to the first rescue opioid analgesic, pain scores at 24 h postoperatively and the incidence of postoperative nausea and vomiting (PONV).

DESIGN

This was a systematic review and meta-analyses of observational studies and randomised controlled trials (RCTs). PRISMA-P guidelines were followed, and the review was registered in PROSPERO. GRADE was used to assess the quality of evidence.

DATA SOURCES

The search was performed from several databases (Ovid MEDLINE, PubMed, Scopus, Web of Science, CINAHL and the Cochrane CENTRAL) from inception up to June 2019.

ELIGIBILITY CRITERIA

RCTs and prospective observational studies that investigated the postoperative analgesic properties of US-guided single shot QLB in adult patients undergoing abdominal or hip surgery were included. QLB was compared with other analgesics.

RESULTS

Twenty-seven studies constituting 1557 patients were reviewed. Twelve studies with 803 patients were included in the meta-analysis on the primary outcome. Overall opioid consumption at 24 h postoperatively was reduced [mean difference, -11.15 (95% CI, -15.33 to -6.97) mg, I2 = 99%, moderate certainty in GRADE] and the time to the first opioid analgesic was longer in patients with QLB: 7 studies with 499 patients, mean difference, 189.32 (95% CI, 114.4 to 264.23) min, I2 = 98%. There were no differences in pain grades. The incidence of PONV was lower in patients with QLB [11 studies with 744 patients, OR 0.40 (95% CI, 0.27 to 0.58), I2 = 7%]. Reported complications and adverse effects of QLB were minimal.

CONCLUSION

QLB reduced postoperative opioid consumption, prolonged the time to the first rescue opioid analgesic and diminished the incidence of PONV. QLB appears to be an applicable option for postoperative analgesia after abdominal and hip surgery.

REGISTRATION NUMBER

PROSPERO, https://www.crd.york.ac.uk/prospero/, CRD42016039921.

Thoracic Epidural Analgesia for Postoperative Pain Management in Liver Transplantation: A 10-year Study on 685 Liver Transplant Recipients

Thoracic epidural analgesia (TEA) is not widely used for postoperative pain management in liver transplantation due to hepatic coagulopathy-related increased risk of inducing an epidural hematoma. However, an increasing number of patients are transplanted for other indications than the end-stage liver disease and without coagulopathy allowing insertion of an epidural catheter.

Spinal Anesthetic in a Patient With a Platelet Count of 7000 × 109/L and Undiagnosed Thrombotic Thrombocytopenic Purpura: A Case Report

A parturient with unknown thrombotic thrombocytopenic purpura (TTP) received spinal anesthesia for cesarean delivery with subsequent discovery of a platelet count of 7000 × 10/L. Neurologic recovery was normal. Limited data exist to determine the risk of spinal epidural hematoma (SEH) in severely thrombocytopenic patients because they often receive alternate labor analgesia or general anesthesia during cesarean delivery. There is reporting bias in the literature toward cases in which severely thrombocytopenic patients sustain complications after regional anesthesia. It is important to report all cases of neuraxial anesthesia in severely thrombocytopenic patients, including those such as ours, wherein patients recover normally.

Trends in practice and safety measures of epidural analgesia: Report of a national survey

BACKGROUND

The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown.

METHODS

We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics.

RESULTS

Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals.

CONCLUSIONS

This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.