Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site

Study design: Case report. Objectives: We report a case of spinal epidural hematoma (SEH) that appeared on the third postoperative day after lumbar spinal anesthesia, far from the needle puncture site. Possible mechanisms and etiological relation to patient's risk factors as well as diagnosis and management of SEH are briefly discussed. Setting: Asklepieion General Hospital of Voula, Athens, Greece. Methods and results: A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved. Conclusion: The possibility of SEH must be considered whenever neurological symptoms occur in the postoperative period, especially after a neuraxial blockade. The causes are multiple, a not-known lesion predisposing to bleeding and hematoma formation may preexist and the anesthetic technique can be directly or indirectly connected to this complication. MRI is the preferred diagnostic method.