Built upon my own experience,by the time I was depressed thinking that I am the culprit who caused the problem.

1. Dr.Sripali Dassanayake

2. Case report
 History
Mr.Kiriganitha
75 years
Warakapola
 c/o sudden painful swelling of Right calf for 1 day
 No history of recent trauma to leg
 No history of fever
 No history of injuries to LL or wounds
 No evidence of filarasis
Admitted to BH warakapola on 13/01/2011
Transferred to TH Kegalle on 14/01/2011 admitted to
ETU at 4pm

3. Past medical history
no past history of bleeding disorders
no history of haematological malignancies
 Not a known diabetic(but on admission FBS was
180mg/dl)
 No hypertension,CVA,TIA
 No chest pain, no IHD,No exertional dyspnoea
 Good exercise tolerance
Past surgical History
History of head injury following fallen from bicycle on
ground 1 year back-scalp laceration sutured under LA-no
intractable bleeding

4. Family history
 No bleeding discrasia
Social history
 A farmer, father of a daughter, living with daughter’s family
On Examination
Pt.In pain
GCS 15/15
Afebrile
not dyspnoeic
Mild pallor+
CVS-PR 80/min regular, good volume
BP-130/80mmHg
Heart in dual rhythm no murmurs
Capillary refilling time<2s

5. Respiratory –B/L equal breath sounds
Few fine crepts on bases
No rhonchi
Abdomen –soft
R/LL-swallen,erythematous calf which is tender and warm to touch
Investigations
 Hb-10.7g/dl PCV-36%
 WBC-10,800 N 67% L 28% M 5% E 2%
 BT-3min CT-4min
 Platelet count-307*1000/ul
 BU-45 Na+138 K+3.8
 ECG-no ischaemia
 USS R/LL-?intra muscular collection of blood,no evidence of DVT

6.  VS opinion to do urgent fasciotomy of R/LL for
compartmental release
 On 14/01/11 at 5pm Sub Arachnoid Block given(single
attempt) under strict aseptic conditions under LA via a 25G
pencil point spinal needle, Heavy Bupivacaine 2.3cc
introduced intrathecally after observing a free flow of clear
CSF.
 Spinal level achieved-L1
 Compartmental release done making 2 surgical incisions on
either side of the R/LL. muscle haematoma found. clots
removed. the exact bleeder not found. tight bandage
applied.
 Recovery uneventful.

7.  Bleeding from wound site found in the night of the same day.
 Re exploration done on the following day.15/01/2011 at 12.30pm
after transfusion of 1U of blood.
 Pre op BP-120/60mmHg PR-80/min
 SAB given in 3rd attempt under absolute aseptic procedure under
LA with Heavy Bupivacaine 1.8cc.
 CSF was blood stained.?traumatic puncture
 Clots were removed and haemostasis achieved. Pt. Kept in the
recovery room for 10min.post op BP-100/60 mmHg ,no other
complains and sent to the ward.

8.  At 7.30pm,Pt.was complaining severe backache.
 Managed as ?positional backache and had been given pain relief,
not informed seniors ,were not suspicious about symptoms.
 Following day Pt. complained of urine retention +weakness of B/L
LL
 O/E of LL
Tone
Power-Grade 1 (flicker of movements only)
Reflexes
 Sensory level-mid thigh(L2)

9.  Seen by CA- Spinal Haematoma need to be excluded .Need
Urgent MRI
 Urgent investigations sent .
Hb-8.3g/dl
BT-2 1/2min
CT-1 1/2min
Platelet count-312*1000
PT-12.6s
INR-1
 VP informed-need urgent MRI to exclude spinal haematoma

10.  Could not get the MRI done on the same day.
Neurosurgical opinion-to start on Methyl Prednisolone until MRI is
available.
 MRI on the following day (at Radiology Unit SBCH):
MRI Thoraco-lumbar spine:-Subdural haematoma at L3-T12 with
cord compression
 Transferred to Neurosurgical unit Kandy
 Neurosurgical opinion-Ct. IV Methyl Prednisolone
No need of surgical evacuation
Conservative Mx only
 Haematological referral to exclude;
 Acquired factor XIII deficiency
 Acquired VWD
 Acquired platelet dysfunction
 Acquired fibrinogen disorder

11.  APTT-28s(normal)
 Haematologist opinion to do 2nd line invetigations;
 Thrombin time
 Clot stabilizing time
 D.D. ?Acquired factor XIII deficiency
 ?Acquired fibrinogendeficiency
/dysfibrinogenemia
 Pt, was started on Cryoprecipitate before completing Ix as
oozing from wound site
 GCS level + spastic paraplegia-CT brain:frontal
ischaemia + cerebral atrophy.......... ?stupor
 Now-regain GCS with slight movements of LL, On
physiotherapy......sensory level came down to below knee...

12. Causes for epidural haematoma
Predisposing factors:
 Pre-existing coagulopathy
 Spinal vascular malformation
 Hypertension
 Therapeutic thrombolysis
 Use of antiplatelet or anticoagulant therapy
Administration of any kind of neuro-axial anaesthesia

13.  Haemorrhagic complications after epidural
anaesthesia- 1:150 000-1:190 000
 After spinal anaesthesia- <1:220 000
 Very infrequent complication but very serious
consequences
 permanent paraplegia

14. Reasons for epidural haematoma
 Anatomical abnormalities
Eg:spinal haemangiomas,vascular lymphomas
 Traumatic puncture with multiple attempts
 Coagulation disorders( 54%) -2ndory to defect in haemostatic
mechanism eg:Leukaemia,Haemophilia,Thrombocytopenia,
cryoglobulinaemia,haemorrhagic diathesis, polycythaemia
 Anticoagulant therapy(Acute or Chronic)(30%)
Among these newest anticoagulants - the very potent platelet
aggregation inhibitors (e.g., ticlopidin),thrombin antagonists
(e.g., melagatran), and factor Xa inhibitors (e.g., fondaparinux)

16. a) T1 scan revealing Isointense linear biconvex mass compressing on the lower thoracic
spinal cord and cauda equina (arrow heads). (b) Same lesion showing heterogenous signal
of hyperintensity (arrow heads) and hypointensity (arrow) on T2 scan

17.  severe Lumbar pain(absence of pain does not exclude
haematoma)
 Motor impairment –flaccid paralysis (if cephalad
migration of haematoma occurs-spastic paralysis)
 Sensory loss with sensory level below the level of
compressed spinal segment
 Sphincter disturbance-Urine retention

18.  Surgical decompression by laminectomy is the
definitive treatment
OUTCOME
 1. Severity at presentation 2. Time from presentation to
surgery
Onset of symptoms Surgery
Within 12 hrs-60%recovery rate
>24 hrs-10% recovery rate
>8hrs known to be associated with worse prognosis
Also if it is Sub Arachnoid Haemorrhage
Or there were pre op neurological deficits

19. • Recognize symptoms
Early • Ix of choice-MRI
diagnosis
• Urgent neurosurgical
Aggressive intervention
treatment

20. Protocol proposal
Detection and management of epidural haematomas related to
anaesthesia in the UK: a national survey of current practice†
 (i) Patients with epidural infusions running should
have observations that include assessment of motor
block made at least every 4 h.
 (ii) These observations should continue for at least 24
h after removal of the epidural catheter.
 (iii) There should be a designated person responsible
for investigating signs suggestive of epidural
haematoma.

21.  (iv) If significant deterioration in motor function
occurs in the absence of a recent bolus dose of local
anaesthetic being administered, the designated person
should be contacted immediately.
 (v) If motor block is attributed to a recent bolus dose
of epidural drugs, reassessment should occur within 2
h.
 (vi) If an epidural infusion is running, it should be
turned off, alternative analgesia instigated as necessary
,and a reassessment of the patient’s motor function
should be made after a defined interval. The motor
block would be expected to resolve if due to overdose
or catheter migration. If motor power does not
improve, remediable causes, including epidural
haematoma or abscess, must be excluded.

22.  (vii) Once an epidural haematoma is suspected, an
MRI scan should be organized immediately, as this is a
potential neurosurgical emergency. A protocol should
be agreed in advance with the diagnostic imaging
service.
 (viii) If MRI scanning is not available in the local
hospital or there will be a delay, then the patient
should be referred to a neurosurgical unit to be
scanned. It may be appropriate to arrange a protocol
with local neurosurgical units to minimize delays in
investigation and treatment.

23. Thank You !