American Journal of Emergency Medicine 33 (2015) 603.e3–603.e4
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Extensive subarachnoid and epidural hematoma after lumbar puncture
Abstract Emergency physicians across the country perform uncomplicated lumbar punctures on shift every day. If a complication does arise, it is often relatively benign, such as back pain at the site of needle insertion or headache and resolves with minimal intervention with no long-term morbidity. However, given the frequency with which the procedure is performed, many physicians will eventually confront rare but serious complications. This case report details the history of a 64 year old woman who presented to the emergency department with back pain shortly after a hospitalization for altered mental status during which she underwent a diagnostic lumbar puncture. She was found to have a significant thoracic and lumbar subarachnoid and epidural hematoma. We discuss the outcome of the case as well as the diagnosis and management of this complication. We also review the literature on performing a lumbar puncture on a patient with coagulopathy. Emergency physicians perform lumbar punctures every day, often in the work-up of a life-threatening diagnosis such as bacterial meningitis. Complications of the procedure are uncommon and often seem trivial when compared with the diagnosis in question. Furthermore, when complications do arise, such as the postlumbar puncture headache or back pain, they are often transient and do not result in long-term morbidity. However, as with any invasive procedure, a lumbar puncture has the potential for serious complication. In this case report, we discuss a 64-year-old woman who presented to the emergency department (ED) with back pain after lumbar puncture and was found to have a subarachnoid and epidural hemorrhage. We discuss the case and outcome as well as the risk factors and management of this uncommon but significant complication. A 64-year-old woman with hypertension, diabetes, hyperlipidemia, and hypothyroidism presented to the ED on March 9th for acute onset of confusion and aphasia concerning for a stroke. Head computed tomography and head and neck computed tomography angiography were unremarkable. She was outside the tissue plasminogen activator window but was given aspirin and admitted to the neurology service. Subsequent magnetic resonance imaging (MRI) was negative for ischemic stroke. To evaluate for viral encephalopathy, she had a lumbar puncture performed that required 5 attempts, which showed zero red blood cells. A repeat lumbar puncture was performed the following day for worsening mental status, and records show 176 red blood cells and a “colorless, clear” sample. Her mental status returned to baseline, and she was discharged on March 13th.
☆ The case report is from a military medical center; however, the authors did not receive any support from the Department of Defense, Washington, DC., USA in addition to their base salaries while writing this report. 0735-6757/Published by Elsevier Inc.
On March 15th, the patient returned to the ED with a 2-day history of worsening of low back pain radiating down the right leg and thigh. It was associated with mild neck stiffness and subjective right leg weakness. She denied bowel or bladder incontinence. She had continued to take her home aspirin after her discharge from the hospital. She was afebrile, had a blood pressure of 141/62 mm Hg, heart rate of 72 beats per minute, respiratory rate of 17 breaths per minute, and oxygen of 98% on room air. Her physical examination showed tenderness over the lumbar spine and 5/5 upper and lower extremity strength, 2+ patellar reflexes, and 1+ ankle jerk reflexes. Her postvoid residual was 19 mL. Her laboratories showed a white blood cell count of 11.5, sodium of 130, and international normalized ratio of 1.0. An MRI of the thoracic and lumbar spine was obtained due to concern for epidural abscess and demonstrated subarachnoid hemorrhage extending from the level of T11 through the sacrum as well as epidural hemorrhage from T11 to L4 (Figure). Neurosurgery was consulted and recommended against surgical intervention because her neurologic examination and MRI were not concerning for cauda equina syndrome. She was admitted to the neurology service for serial examinations and started on a short course of dexamethasone. Patient was discharged home the following day after stable neurologic examinations and improvement in her back pain, and her aspirin was discontinued. She did, however, return to the ED on March 19th for worsening low back pain, and a repeat MRI showed no significant change in her hematoma. She was admitted at that time for management of her pain and hyponatremia of 120 that was thought to be due to syndrome of inappropriate antidiuretic hormone. Serious bleeding is a known although rare complication after lumbar puncture. There have been cases of spinal hematoma reported in the neurosurgery and anesthesia literature but very few in the emergency medicine literature. Emergency medicine physicians should have a high index of suspicion for this condition in patient who presents with acute low back pain who have undergone lumbar punctures. There are multiple case reports of hematoma after lumbar puncture or epidural placement, in some cases resulting in permanent neurologic dysfunction [1-5]. Patients who have severe thrombocytopenia and those who have receive anticoagulant therapy before or immediately after undergoing lumbar puncture have increased risk of bleeding. Lumbar puncture is generally contraindicated in patients with thrombocytopenia (platelet count b50 000-80 000) or international normalized ratio greater than 1.4 before correcting the abnormality. Our patient had normal platelet count and coagulation studies; however, she was on aspirin at home and received aspirin on day of admission for her suspected stroke. Interestingly, aspirin has not been shown to increase the risk of serious bleeding after lumbar puncture. In prospective study done by Horlocker et al [6], of the 924 patients who underwent spinal or epidural
603.e4
M. Myers et al. / American Journal of Emergency Medicine 33 (2015) 603.e3–603.e4
regarding subarachnoid hematomas, 31 patients were identified to have an iatrogenic hematoma related to either lumbar puncture or spinal anesthesia. Of those 31 patients, 23 were coagulapathic or were taking anticoagulants. The same review found that, of all patients with either iatrogenic or spontaneous subarachnoid bleeding, 36% had an unsatisfactory neurology outcome [8]. The article also noted that recovery may be lower for a subarachnoid hematoma because of the direct pressure on the roots of the spinal cord without any intervening membranes. Regardless of the origin of the bleeding, if hard neurologic signs are present, the treatment will likely involve spinal decompressive surgery. As with any spinal cord compression syndrome, the time to surgery plays an important factor in recovery after treatment. In 1 study, patients who went to the Operating Room (OR) within 12 hours after diagnosis had improved neurology recovery. However, the same study notes that even patients with a delayed presentation may benefit from decompressive surgery [9]. Although rare, spinal hematoma can be a devastating complication after a lumbar puncture because it can lead to neurologic disability. Therefore, it is crucial for emergency physicians to question patients about any recent lumbar punctures or spinal procedures and to consider the diagnosis of a spinal hematoma when approaching a patient with acute back pain. Once there is a suspicion for spinal hematoma, MRI should be considered the first-line diagnostic modality. Once the diagnosis is confirmed, emergent neurosurgical consultation is crucial in maximizing the chances of neurologic recovery.
Figure. Lateral thoracic and lumbar MRI showing large hematoma.
anesthesia before orthopedic procedures, 386 were taking antiplatelet therapy and 193 were taking aspirin. Their data showed that neither aspirin nor any other antiplatelet agents were associated with increased risk of spinal hematoma. However, clopidogrel, ticlodipine, or GPIIa/ IIIb receptor antagonist were not taken by these patients, so the risk of bleeding is unknown with these agents. Other risk factors that increase the risk of minor bleeding at the catheter placement include female sex, multiple needle passes, large needle gauge, increased age, and history of easy bruising [6]. The etiology of bleeding during or after Lumbar Puncture (LP) often remains undetermined. Most bleeding may be due to a venous plexus injury, in which case the low pressure of the venous system should lead to spontaneous resolution. This may come as a comfort to those reading this report, as the authors suspect that most physicians have at some time performed a traumatic lumbar puncture. However, there are other sources of bleeding, such as the epidural arteries, which may lead to serious morbidity [7]. Once bleeding occurs, the patient is at high risk for permanent neurologic injury. The patient discussed in this report had both subarachnoid (intrathecal) and epidural hematomas. An epidural hematoma after lumbar puncture may present with back or radicular pain, and symptoms can quickly progress to cauda equina. If the diagnosis is considered, the most sensitive imaging available is MRI [7]. Furthermore, MRI would allow the physician to look for possible other etiologies of back pain after LP such as epidural abscess. In a previous review of the literature
Melissa Myers, MD⁎ Linda Meyers, MD Walter A. Fink, MD Madigan Army Medical Center, Tacoma, WA ⁎ Corresponding author at: Madigan Army Medical Center, Department of Emergency Medicine, 9040 Jackson Ave, Tacoma, WA 98431 Tel.: +1 540 903 7801 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.09.043
References [1] Verduzco. Subdural hematoma after epidural blood patch. Int J Obstet Anesth 1996; 43(3):306–9. [2] Scott EW, Cazenave CR, Virapongse C. Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management. Neurosurgery 1989;25(2):287–93. [3] Kebaish KM, Awad JN. Spinal epidural hematoma causing acute cauda equina syndrome. Neurosurg Focus 2004;16(6):1–4. [4] Gurkanlar D, Acikbas C, Cengiz GK, Tuncer R. Lumbar epidural hematoma following lumbar puncture: the role of high dose LMWH and late surgery. A case report. Neurocirugia 2007;18(1):52–5. [5] Lee SJ, Lin YY, Hsu CW, Chu SJ, Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci 2009;337(2):143–5. [6] Horlocker TT, Wedel DJ, Schroeder DR, Rose SH, Elliott BA, McGregor DG, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80(2):303–9. [7] Nolli M, Crispino M, Nicosia F, Borghi B, Montone N. Diagnosis and therapy of intrathecal bleeding. Minerva Anestesiol 2001;67(9 Suppl. 1):82–91. [8] Domenicucci M, Ramieri A, Paolini S, Russo N, Occhiogrosso G, Di Biasi C, et al. Spinal subarachnoid hematomas: our experience and literature review. Acta Neurochir 2005;147(7):741–50. [9] Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995;83(1):1–7.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Extensive subarachnoid and epidural hematoma after lumbar puncture
Abstract Emergency physicians across the country perform uncomplicated lumbar punctures on shift every day. If a complication does arise, it is often relatively benign, such as back pain at the site of needle insertion or headache and resolves with minimal intervention with no long-term morbidity. However, given the frequency with which the procedure is performed, many physicians will eventually confront rare but serious complications. This case report details the history of a 64 year old woman who presented to the emergency department with back pain shortly after a hospitalization for altered mental status during which she underwent a diagnostic lumbar puncture. She was found to have a significant thoracic and lumbar subarachnoid and epidural hematoma. We discuss the outcome of the case as well as the diagnosis and management of this complication. We also review the literature on performing a lumbar puncture on a patient with coagulopathy. Emergency physicians perform lumbar punctures every day, often in the work-up of a life-threatening diagnosis such as bacterial meningitis. Complications of the procedure are uncommon and often seem trivial when compared with the diagnosis in question. Furthermore, when complications do arise, such as the postlumbar puncture headache or back pain, they are often transient and do not result in long-term morbidity. However, as with any invasive procedure, a lumbar puncture has the potential for serious complication. In this case report, we discuss a 64-year-old woman who presented to the emergency department (ED) with back pain after lumbar puncture and was found to have a subarachnoid and epidural hemorrhage. We discuss the case and outcome as well as the risk factors and management of this uncommon but significant complication. A 64-year-old woman with hypertension, diabetes, hyperlipidemia, and hypothyroidism presented to the ED on March 9th for acute onset of confusion and aphasia concerning for a stroke. Head computed tomography and head and neck computed tomography angiography were unremarkable. She was outside the tissue plasminogen activator window but was given aspirin and admitted to the neurology service. Subsequent magnetic resonance imaging (MRI) was negative for ischemic stroke. To evaluate for viral encephalopathy, she had a lumbar puncture performed that required 5 attempts, which showed zero red blood cells. A repeat lumbar puncture was performed the following day for worsening mental status, and records show 176 red blood cells and a “colorless, clear” sample. Her mental status returned to baseline, and she was discharged on March 13th.
☆ The case report is from a military medical center; however, the authors did not receive any support from the Department of Defense, Washington, DC., USA in addition to their base salaries while writing this report. 0735-6757/Published by Elsevier Inc.
On March 15th, the patient returned to the ED with a 2-day history of worsening of low back pain radiating down the right leg and thigh. It was associated with mild neck stiffness and subjective right leg weakness. She denied bowel or bladder incontinence. She had continued to take her home aspirin after her discharge from the hospital. She was afebrile, had a blood pressure of 141/62 mm Hg, heart rate of 72 beats per minute, respiratory rate of 17 breaths per minute, and oxygen of 98% on room air. Her physical examination showed tenderness over the lumbar spine and 5/5 upper and lower extremity strength, 2+ patellar reflexes, and 1+ ankle jerk reflexes. Her postvoid residual was 19 mL. Her laboratories showed a white blood cell count of 11.5, sodium of 130, and international normalized ratio of 1.0. An MRI of the thoracic and lumbar spine was obtained due to concern for epidural abscess and demonstrated subarachnoid hemorrhage extending from the level of T11 through the sacrum as well as epidural hemorrhage from T11 to L4 (Figure). Neurosurgery was consulted and recommended against surgical intervention because her neurologic examination and MRI were not concerning for cauda equina syndrome. She was admitted to the neurology service for serial examinations and started on a short course of dexamethasone. Patient was discharged home the following day after stable neurologic examinations and improvement in her back pain, and her aspirin was discontinued. She did, however, return to the ED on March 19th for worsening low back pain, and a repeat MRI showed no significant change in her hematoma. She was admitted at that time for management of her pain and hyponatremia of 120 that was thought to be due to syndrome of inappropriate antidiuretic hormone. Serious bleeding is a known although rare complication after lumbar puncture. There have been cases of spinal hematoma reported in the neurosurgery and anesthesia literature but very few in the emergency medicine literature. Emergency medicine physicians should have a high index of suspicion for this condition in patient who presents with acute low back pain who have undergone lumbar punctures. There are multiple case reports of hematoma after lumbar puncture or epidural placement, in some cases resulting in permanent neurologic dysfunction [1-5]. Patients who have severe thrombocytopenia and those who have receive anticoagulant therapy before or immediately after undergoing lumbar puncture have increased risk of bleeding. Lumbar puncture is generally contraindicated in patients with thrombocytopenia (platelet count b50 000-80 000) or international normalized ratio greater than 1.4 before correcting the abnormality. Our patient had normal platelet count and coagulation studies; however, she was on aspirin at home and received aspirin on day of admission for her suspected stroke. Interestingly, aspirin has not been shown to increase the risk of serious bleeding after lumbar puncture. In prospective study done by Horlocker et al [6], of the 924 patients who underwent spinal or epidural
603.e4
M. Myers et al. / American Journal of Emergency Medicine 33 (2015) 603.e3–603.e4
regarding subarachnoid hematomas, 31 patients were identified to have an iatrogenic hematoma related to either lumbar puncture or spinal anesthesia. Of those 31 patients, 23 were coagulapathic or were taking anticoagulants. The same review found that, of all patients with either iatrogenic or spontaneous subarachnoid bleeding, 36% had an unsatisfactory neurology outcome [8]. The article also noted that recovery may be lower for a subarachnoid hematoma because of the direct pressure on the roots of the spinal cord without any intervening membranes. Regardless of the origin of the bleeding, if hard neurologic signs are present, the treatment will likely involve spinal decompressive surgery. As with any spinal cord compression syndrome, the time to surgery plays an important factor in recovery after treatment. In 1 study, patients who went to the Operating Room (OR) within 12 hours after diagnosis had improved neurology recovery. However, the same study notes that even patients with a delayed presentation may benefit from decompressive surgery [9]. Although rare, spinal hematoma can be a devastating complication after a lumbar puncture because it can lead to neurologic disability. Therefore, it is crucial for emergency physicians to question patients about any recent lumbar punctures or spinal procedures and to consider the diagnosis of a spinal hematoma when approaching a patient with acute back pain. Once there is a suspicion for spinal hematoma, MRI should be considered the first-line diagnostic modality. Once the diagnosis is confirmed, emergent neurosurgical consultation is crucial in maximizing the chances of neurologic recovery.
Figure. Lateral thoracic and lumbar MRI showing large hematoma.
anesthesia before orthopedic procedures, 386 were taking antiplatelet therapy and 193 were taking aspirin. Their data showed that neither aspirin nor any other antiplatelet agents were associated with increased risk of spinal hematoma. However, clopidogrel, ticlodipine, or GPIIa/ IIIb receptor antagonist were not taken by these patients, so the risk of bleeding is unknown with these agents. Other risk factors that increase the risk of minor bleeding at the catheter placement include female sex, multiple needle passes, large needle gauge, increased age, and history of easy bruising [6]. The etiology of bleeding during or after Lumbar Puncture (LP) often remains undetermined. Most bleeding may be due to a venous plexus injury, in which case the low pressure of the venous system should lead to spontaneous resolution. This may come as a comfort to those reading this report, as the authors suspect that most physicians have at some time performed a traumatic lumbar puncture. However, there are other sources of bleeding, such as the epidural arteries, which may lead to serious morbidity [7]. Once bleeding occurs, the patient is at high risk for permanent neurologic injury. The patient discussed in this report had both subarachnoid (intrathecal) and epidural hematomas. An epidural hematoma after lumbar puncture may present with back or radicular pain, and symptoms can quickly progress to cauda equina. If the diagnosis is considered, the most sensitive imaging available is MRI [7]. Furthermore, MRI would allow the physician to look for possible other etiologies of back pain after LP such as epidural abscess. In a previous review of the literature
Melissa Myers, MD⁎ Linda Meyers, MD Walter A. Fink, MD Madigan Army Medical Center, Tacoma, WA ⁎ Corresponding author at: Madigan Army Medical Center, Department of Emergency Medicine, 9040 Jackson Ave, Tacoma, WA 98431 Tel.: +1 540 903 7801 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2014.09.043
References [1] Verduzco. Subdural hematoma after epidural blood patch. Int J Obstet Anesth 1996; 43(3):306–9. [2] Scott EW, Cazenave CR, Virapongse C. Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management. Neurosurgery 1989;25(2):287–93. [3] Kebaish KM, Awad JN. Spinal epidural hematoma causing acute cauda equina syndrome. Neurosurg Focus 2004;16(6):1–4. [4] Gurkanlar D, Acikbas C, Cengiz GK, Tuncer R. Lumbar epidural hematoma following lumbar puncture: the role of high dose LMWH and late surgery. A case report. Neurocirugia 2007;18(1):52–5. [5] Lee SJ, Lin YY, Hsu CW, Chu SJ, Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci 2009;337(2):143–5. [6] Horlocker TT, Wedel DJ, Schroeder DR, Rose SH, Elliott BA, McGregor DG, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80(2):303–9. [7] Nolli M, Crispino M, Nicosia F, Borghi B, Montone N. Diagnosis and therapy of intrathecal bleeding. Minerva Anestesiol 2001;67(9 Suppl. 1):82–91. [8] Domenicucci M, Ramieri A, Paolini S, Russo N, Occhiogrosso G, Di Biasi C, et al. Spinal subarachnoid hematomas: our experience and literature review. Acta Neurochir 2005;147(7):741–50. [9] Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995;83(1):1–7.
