CONTINUING EDUCATION Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills ALAN H. DANIELS, MD; STEVEN S. SCHIEBERT, DO; MARK A. PALUMBO, MD
1.1
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indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #15502 Session: #0001 Fee: Members $8.80, Nonmembers $17.60 The contact hours for this article expire January 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to rapid identification and treatment of postoperative symptomatic spinal epidural hematoma (SEH) after lumbar spine surgery.
Objectives 1. Discuss diagnosis of postoperative symptomatic SEH. 2. Explain the presentation of symptomatic SEH. 3. Describe complications of postoperative symptomatic SEH. 4. Identify risk factors for developing symptomatic SEH.
Conflict of Interest Disclosures Drs Daniels and Schiebert have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Dr Palumbo has declared financial relationships with Stryker, Kalamazoo, MI, and Globus Medical, Audubon, PA, as a consultant and lecturer and also with a variety of law firms as an expert witness, which could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.03.016
Ó AORN, Inc, 2015
January 2015
Vol 101 No 1
AORN Journal j 85
Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills 1.1 ALAN H. DANIELS, MD; STEVEN S. SCHIEBERT, DO; MARK A. PALUMBO, MD
www.aorn.org/CE
ABSTRACT Symptomatic spinal epidural hematoma (SEH) is a rare but serious complication that may occur after lumbar spine surgery. Prompt recognition of this complication depends on the diagnostic skills of perioperative nursing personnel, particularly postanesthesia care unit nurses. Analysis of a composite of patients undergoing spinal surgery suggests that neurological and functional outcomes of patients with symptomatic lumbar SEH often depend on the time interval between symptom onset and surgical evacuation of the hematoma. Clinicians should consider a diagnosis of symptomatic SEH if there is a change in the patient’s neurological status during the first several hours after lumbar spine surgery. Suspicion of postoperative symptomatic SEH should prompt clinicians to notify the responsible surgeon without delay. AORN J 101 (January 2015) 86-90. Ó AORN, Inc, 2015. http://dx.doi .org/10.1016/j.aorn.2014.03.016 Key words: spinal surgery, symptomatic spinal epidural hematoma, symptomatic SEH, postoperative SEH, symptomatic lumber SEH, lumbar spine surgery, neurological injury, neurological deficit.
M
ost spinal epidural hematomas (SEHs) that occur after lumbar spine surgery are asymptomatic, and SEHs have been reported to occur in up to 58% of patients undergoing this procedure as identified with magnetic resonance imaging (MRI).1 Symptomatic SEH is a far less common complication after lumbar spine surgery, occurring in 0.1%2-4 to 1%5 of patients. An SEH can lead to serious neurological compromise if not diagnosed and treated in an expeditious manner.
DIAGNOSIS Rapid diagnosis and surgical evacuation of postoperative lumbar SEH are imperative to provide the best chance for complete neurological recovery and a positive clinical outcome. Prompt recognition of symptomatic lumbar SEH often depends on the diagnostic skills of the perioperative nursing personnel. The development of new neurological deficits (eg, numbness, tingling, weakness, loss of bladder control) after lumbar spine surgery should raise suspicion for symptomatic SEH.6 According http://dx.doi.org/10.1016/j.aorn.2014.03.016
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DIAGNOSING AND TREATING SPINAL EPIDURAL HEMATOMA to Yi et al,7 the clinical presentation of acute symptomatic SEH is severe pain at the level of surgery followed by development of n
lower extremity radicular pain (33.3%), bladder dysfunction (33.3%), or n lower extremity motor weakness and sensory loss (88.9%). n
Magnetic resonance imaging studies have a high false-positive rate for asymptomatic SEH. Therefore, the routine use of postoperative MRI is an impractical diagnostic tool for the detection of symptomatic SEH.1,8,9 Given that the specificity of MRI is low in the diagnosis of symptomatic SEH during the immediate postoperative period, clinicians must base their diagnosis on the patient’s symptoms and physical signs. Magnetic resonance imaging after lumbar decompression surgery frequently will identify asymptomatic SEH, however MRI is also a useful adjunct to the diagnosis and treatment of symptomatic SEH in certain situations. Specifically, MRI can be of use in patients with postoperative SEH who have questionable symptoms and no significant neural deficit (eg, a slowly evolving cauda equina syndrome, which is defined as progressive loss of function of the lumbar plexus nerve roots of the spinal canal below the termination of the spinal cord). Typically, the surgeon would prefer for an MRI to be performed to determine the location, craniocaudal extent, and compressive effect of the hematoma. The real problem with the use of MRI is that, depending on the institution, it can take multiple hours to complete and delays the start of definitive surgical treatment. Therefore, in patients who have rapidly evolving symptoms and signs of significant neurological dysfunction, especially if an MRI cannot be immediately performed, the surgeon may choose to forego MRI and proceed directly to surgery. CASE STUDY The following is a clinical case study composite of commonly seen patients experiencing symptoms of
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SEH that emphasizes the need for early recognition and treatment of postoperative symptomatic SEH. The patient’s primary care physician referred Mr C, a 28-year-old man with severe lower back and right lower extremity pain, to the surgeon. Mr C demonstrated no motor or sensory deficits on physical examination. MRI analysis showed a large, right, paracentral disc herniation compressing the S1 nerve root. The surgeon diagnosed a right S1 radiculopathy. After eight weeks of conservative management (eg, physical therapy, selective nerve root blocks) that failed to resolve the severe radicular leg pain, Mr C elected to proceed with lumbar spine surgery. The surgeon performed a right L5-S1 laminotomy and discectomy with decompression of the S1 nerve root without complication. Adequate hemostasis was achieved at the conclusion of the decompression. After standard wound closure, the OR team transferred Mr C to the postanesthesia care unit (PACU) in stable condition. Within one hour of arrival in the PACU, Mr C told the PACU nurse that he had increasing pain and numbness in his right lower extremity. Over the subsequent 15 to 30 minutes, Mr C also developed paresthesias in the left foot and the perineum. Recognizing the symptoms as atypical and indicative of neurological compromise associated with symptomatic SEH, the nurse immediately contacted the attending surgeon, who evaluated Mr C at the bedside. On physical examination, the surgeon noted that the incision site was intact, without evidence of drainage or swelling. Mr C demonstrated no muscle weakness in either lower extremity, and rectal examination demonstrated normal tone and voluntary contraction of the external anal sphincter. However, Mr C showed diminished pinprick sensation over the perineum and in the right S1 and S2 dermatomes. With a presumed diagnosis of symptomatic lumbar SEH and impending cauda equina syndrome, the surgeon decided to return Mr C immediately to surgery for exploration of the surgical site and possible hematoma evacuation. The surgeon and PACU nurse then contacted the OR nurse AORN Journal j 87
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manager, who arranged to have Mr C immediately transferred to the OR. The surgeon initiated exploration of the surgical wound less than 2.5 hours after completion of the initial procedure and identified an epidural hematoma at the L5/S1 level; he evacuated the hematoma, achieving full decompression of the caudal nerve roots. Mr C had a complete neurological and functional recovery. Sensation returned to normal within two weeks of surgery. At his six-week follow-up appointment, Mr C had no residual pain, and he returned to work in his usual occupation as a construction worker. DISCUSSION Most research regarding symptomatic SEH after lumbar spine surgery is more than a decade old. The literature remains important, however, because of the rarity of this clinical entity and the paucity of relevant published reports. Timing of Presentation and Treatment The patient in the composite case study developed symptoms associated with symptomatic SEH within one hour of completion of the initial spinal procedure.4 Amiri et al9 reported that the median time for onset of initial symptoms of SEH is 2.7 hours after surgery and the maximum neurological deficit occurs at the median time of 22.8 minutes after onset of the initial symptomatology. These findings highlight the importance of frequent monitoring, nursing assessment, and careful documentation of neurological status within the first four hours after surgery. Postoperative symptomatic SEH can have devastating effects on neurological outcomes. In a retrospective review of 3,720 patients, nine patients (0.24%) developed postoperative symptomatic SEH. After decompression, clinical outcomes revealed n
complete neurological recovery in only three of the patients (33.3%), n incomplete recovery in five of the patients (55.6%), and n no change in the neurological status of one of the patients (11.1%).7
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Generally, the patient’s neurological outcome after surgical decompression is related to the severity of preoperative neurological deficits.10 The extent of recovery also depends on the time interval from the moment of diagnosis of symptomatic SEH to the surgical decompression.11,12 In the composite case study presented in this report, the surgical team returned the patient to the OR within two to 2.5 hours of the initial surgery and one to 1.5 hours after the onset of his symptoms. This suggests that the nurse’s prompt recognition of neurological symptoms and the surgeon’s urgent surgical evacuation of the hematoma resulted in a positive outcome and complete neurological recovery. Clinical case studies support the need for urgency to decompress postoperative lumbar SEH. Cabana et al5 reported positive outcomes in eight of 10 patients with postoperative SEH if decompression surgery was performed within 1.25 to four hours of the start of the repeat decompression procedure. In patients with delayed decompression (eg, a delay of return to the operating room more than four hours from symptom onset), permanent loss of sphincter function or complete paralysis ensued. Several studies have documented a direct correlation between the extent of the neurological recovery and a short time interval from diagnosis to decompression.4,13-16 The composite case study presented in this report demonstrates that early decompression of the spinal canal has the potential to result in complete neurological recovery. Risk Factors Several studies have examined risk factors for the development of symptomatic SEH after lumbar spine surgery.2,9,17-19 Awad et al17 conducted a review of 14,932 patients who underwent spine surgery between 1984 and 2002. Preoperative risk factors for SEH were n
use of nonsteroidal anti-inflammatory drugs preoperatively, n Rh-positive blood type, and n aged 60 years or older.
DIAGNOSING AND TREATING SPINAL EPIDURAL HEMATOMA
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TABLE 1. Risk Factors for Symptomatic Spinal Epidural Hematoma Preoperative risks n n n n n n
Aged 60 years or older Alcohol consumption Use of nonsteroidal anti-inflammatory drugs Preoperative coagulopathy Previous spinal surgery Rh-positive blood group
1-3
Intraoperative risks n n n n
Blood loss > 1 L Extensive epidural space exposure Hemoglobin level < 10 g/dL Multilevel procedures
Postoperative risks n
International normalized ratio > 2.0 within the first 48 hr after surgery
1. Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila Pa 1976). 2002;27(15): 1670-1673. 2. Amiri AR Fouyas IP, Cro S, Casey AT. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J. 2013; 13(2):134-140. 3. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87(9):1248-1252.
Intraoperative risk factors for SEH included n
requiring surgical intervention on more than five spinal levels, n hemoglobin level less than 10 g/dL, and n blood loss greater than 1 L. In that same study, the researchers determined that the single postoperative risk factor for the development of symptomatic SEH was an international normalized ratio greater than 2.0 within the first 48 hours after surgery (Table 1). Another case-controlled, retrospective study conducted by Kou et al2 demonstrated that significant risk factors for the development of postoperative symptomatic SEH were multilevel procedures and preoperative coagulopathy. Amiri et al9 reported that significant risk factors for the development of postoperative SEH were preoperative alcohol intake, multilevel procedures, and previous spinal surgery. The only significant risk factor for the development of symptomatic SEH in the case study patient was an Rh-positive blood group. The patient underwent a single-level discectomy, which suggests that even relatively minor lumbar spine surgery may lead to SEH in otherwise healthy young patients.18,19
PERIOPERATIVE NURSING IMPLICATIONS Perioperative nursing personnel should be aware of the risk factors for symptomatic SEH after lumbar spine surgery as well as the timing of presentation and need for rapid treatment. Prompt and direct communication between the PACU nurse and the attending surgeon will help guide selection of appropriate interventions. This clinical case study was presented at nursing grand rounds as well as the department of orthopedic grand rounds in an effort to educate all personnel involved in the care of patients undergoing spinal surgery regarding the risk factors for and presenting symptoms of symptomatic postoperative SEH. CONCLUSION Symptomatic SEH after lumbar spine surgery can lead to serious neurological compromise. Although the reported incidence of symptomatic SEH is low compared with asymptomatic SEH, the potentially devastating consequences make prompt diagnosis and management essential. If SEH is suspected, perioperative nurses should contact the surgeon without delay. Neurological and functional recovery depends on the time interval from symptom onset to evacuation of the SEH. Early decompression of the spinal canal has the potential to result in
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complete neurological recovery. Prompt recognition and reporting by perioperative nurses can help achieve a positive clinical outcome. Editor’s note: The patient in the case study presented in this article is a composite and not representative of an actual patient. References 1. Sokolowski MJ, Garvey TA, Perl J II, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine (Phila PA 1976). 2008; 33(1):108-113. 2. Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila PA 1976). 2002;27(15):1670-1673. 3. Scavarda D, Peruzzi P, Bazin A, et al. Postoperative spinal extradural hematomas. 14 cases. Review [in French]. Neurochirurgie. 1997;43(4):220-227. 4. 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. 5. Cabana F, Pointillart V, Vital J, Senegas J. Postoperative compressive spinal epidural hematomas. 15 cases and review of the literature [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(4):335-345. 6. Johnston RA. The management of acute spinal cord compression. J Neurol Neurosurg Psychiatry. 1993; 56(10):1046-1054. 7. Yi S, Yoon DH, Kim KN, Kim SH, Shin HC. Postoperative spinal epidural hematoma: risk factor and clinical outcome. Yonsei Med J. 2006;47(3):326-332. 8. Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J. 2003; 3(2):125-129. 9. Amiri AR, Fouyas IP, Cro S, Casey AT. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J. 2013;13(2):134-140. 10. Foo D, Rossier AB. Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas. Surg Neurol. 1981;15(5):389-401. 11. Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am. 1995; 77(7):1042-1049. 12. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79(6):1165-1177. 13. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg. 1984;61(6):143-148.
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DANIELSdSCHIEBERTdPALUMBO 14. Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 1980;53(6):749-755. 15. Cooper DW. Spontaneous spinal epidural hematoma. Case report. J Neurosurg. 1967;26(3):343-345. 16. Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM. Efficacy of closed wound suction drainage after single-level lumbar laminectomy. J Spinal Disord. 1996;9(5):401-403. 17. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of postoperative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87(9):1248-1252. 18. Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci. 1990; 98(2-3):121-138. 19. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ Jr. Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3,475 patients from the National Surgical Quality Improvement Program. J Bone Joint Surg Am. 2011;93(17):1577-1582.
Alan H. Daniels, MD, is a clinical instructor in the orthopedic department at Rhode Island Hospital, Providence. Dr Daniels has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Steven S. Schiebert, DO, is a clinical instructor in the orthopedic department at Rhode Island Hospital, Providence. Dr Schiebert has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Mark A. Palumbo, MD, is an associate professor of spine surgery in the orthopedic department at Rhode Island Hospital, Providence. Dr Palumbo has declared financial relationships with Stryker, Kalamazoo, MI, and Globus Medical, Audubon, PA, as a consultant and lecturer and also with a variety of law firms as an expert witness, which could be perceived as posing potential conflicts of interest in the publication of this article.
EXAMINATION
1.1
CONTINUING EDUCATION
www.aorn.org/CE Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills
PURPOSE/GOAL To provide the learner with knowledge specific to rapid identification and treatment of postoperative symptomatic spinal epidural hematoma (SEH) after lumbar spine surgery.
OBJECTIVES 1. 2. 3. 4.
Discuss diagnosis of postoperative symptomatic SEH. Explain the presentation of symptomatic SEH. Describe complications of postoperative symptomatic SEH. Identify risk factors for developing symptomatic SEH.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
Most spinal epidural hematomas (SEHs) that occur after lumbar spine surgery are asymptomatic. a. true b. false The clinical presentation of acute-onset SEH is described as the patient developing severe pain at the level of surgery followed by development of one or more of the following complications: 1. bladder dysfunction. 2. lethargy and confusion. 3. lower extremity motor weakness and subsequent sensory loss. 4. lower extremity radicular pain. a. 1 and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
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3.
Magnetic resonance imaging (MRI) scans have a high true-positive rate for asymptomatic SEH; therefore, routine postoperative MRI is advisable. a. true b. false
4.
Clinicians must base the diagnosis of symptomatic SEH during the immediate postoperative period on 1. a routine MRI. 2. a lumbar puncture. 3. the patient’s clinical symptoms. 4. the physical examination. a. 1 and 2 b. 3 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
5.
Acute loss of function of the lumbar plexus nerve roots of the spinal canal below the termination of the spinal cord is called a. cauda equina syndrome.
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b. conus medullaris syndrome. c. spastic paraplegia with Kallmann syndrome. d. tethered spinal syndrome. 6.
The median time for onset of initial symptoms of SEH is ________ hours after surgery. a. 1.2 b. 1.7 c. 2.2 d. 2.7
7.
In a retrospective review of 3,720 patients, nine patients developed postoperative SEH, of which 1. 11.1% had no change in their neurological status. 2. 33.3% achieved complete neurological recovery. 3. 55.6% achieved incomplete recovery. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
8.
Generally, the patient’s neurological outcome after surgical decompression is related to the 1. patient’s age (ie, those older than 50 years of age have an increased risk of poor outcome). 2. severity of preoperative neurological deficits. 3. time interval from the moment of diagnosis of symptomatic SEH to the surgical decompression.
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4.
placement of a surgical drain at the conclusion of the surgery. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
9.
In a review of 14,932 patients, preoperative risk factors for SEH were 1. symptom onset more than three years previously. 2. Rh-positive blood type. 3. use of nonsteroidal anti-inflammatory drugs. 4. use of opioid narcotics before surgery. 5. age of 60 years or older. a. 1 and 4 b. 2 and 5 c. 2, 3, and 5 d. 1, 2, 3, 4, and 5
10.
Researchers determined that the single postoperative risk factor for symptomatic SEH was a. an international normalized ratio greater than 2.0 within the first 48 hours after surgery. b. a hemoglobin level less than 10 g/dL. c. blood loss greater than 1 L. d. a required surgical procedure on more than two operative levels.
LEARNER EVALUATION
1.1
CONTINUING EDUCATION PROGRAM
www.aorn.org/CE Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http:// www.aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss diagnosis of postoperative symptomatic spinal epidural hematoma (SEH). Low 1. 2. 3. 4. 5. High 2. Explain the presentation of symptomatic SEH. Low 1. 2. 3. 4. 5. High 3. Describe complications of postoperative symptomatic SEH. Low 1. 2. 3. 4. 5. High 4. Identify risk factors for developing symptomatic SEH. Low 1. 2. 3. 4. 5. High CONTENT 5. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 6. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 7. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.) 8A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other:________________________________ 8B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 9. Our accrediting body requires that we verify the time you needed to complete the 1.1 continuing education contact hour (66-minute) program: ________________________________
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1.1
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #15502 Session: #0001 Fee: Members $8.80, Nonmembers $17.60 The contact hours for this article expire January 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to rapid identification and treatment of postoperative symptomatic spinal epidural hematoma (SEH) after lumbar spine surgery.
Objectives 1. Discuss diagnosis of postoperative symptomatic SEH. 2. Explain the presentation of symptomatic SEH. 3. Describe complications of postoperative symptomatic SEH. 4. Identify risk factors for developing symptomatic SEH.
Conflict of Interest Disclosures Drs Daniels and Schiebert have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Dr Palumbo has declared financial relationships with Stryker, Kalamazoo, MI, and Globus Medical, Audubon, PA, as a consultant and lecturer and also with a variety of law firms as an expert witness, which could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2014.03.016
Ó AORN, Inc, 2015
January 2015
Vol 101 No 1
AORN Journal j 85
Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills 1.1 ALAN H. DANIELS, MD; STEVEN S. SCHIEBERT, DO; MARK A. PALUMBO, MD
www.aorn.org/CE
ABSTRACT Symptomatic spinal epidural hematoma (SEH) is a rare but serious complication that may occur after lumbar spine surgery. Prompt recognition of this complication depends on the diagnostic skills of perioperative nursing personnel, particularly postanesthesia care unit nurses. Analysis of a composite of patients undergoing spinal surgery suggests that neurological and functional outcomes of patients with symptomatic lumbar SEH often depend on the time interval between symptom onset and surgical evacuation of the hematoma. Clinicians should consider a diagnosis of symptomatic SEH if there is a change in the patient’s neurological status during the first several hours after lumbar spine surgery. Suspicion of postoperative symptomatic SEH should prompt clinicians to notify the responsible surgeon without delay. AORN J 101 (January 2015) 86-90. Ó AORN, Inc, 2015. http://dx.doi .org/10.1016/j.aorn.2014.03.016 Key words: spinal surgery, symptomatic spinal epidural hematoma, symptomatic SEH, postoperative SEH, symptomatic lumber SEH, lumbar spine surgery, neurological injury, neurological deficit.
M
ost spinal epidural hematomas (SEHs) that occur after lumbar spine surgery are asymptomatic, and SEHs have been reported to occur in up to 58% of patients undergoing this procedure as identified with magnetic resonance imaging (MRI).1 Symptomatic SEH is a far less common complication after lumbar spine surgery, occurring in 0.1%2-4 to 1%5 of patients. An SEH can lead to serious neurological compromise if not diagnosed and treated in an expeditious manner.
DIAGNOSIS Rapid diagnosis and surgical evacuation of postoperative lumbar SEH are imperative to provide the best chance for complete neurological recovery and a positive clinical outcome. Prompt recognition of symptomatic lumbar SEH often depends on the diagnostic skills of the perioperative nursing personnel. The development of new neurological deficits (eg, numbness, tingling, weakness, loss of bladder control) after lumbar spine surgery should raise suspicion for symptomatic SEH.6 According http://dx.doi.org/10.1016/j.aorn.2014.03.016
86 j AORN Journal January 2015 Vol 101 No 1
Ó AORN, Inc, 2015
DIAGNOSING AND TREATING SPINAL EPIDURAL HEMATOMA to Yi et al,7 the clinical presentation of acute symptomatic SEH is severe pain at the level of surgery followed by development of n
lower extremity radicular pain (33.3%), bladder dysfunction (33.3%), or n lower extremity motor weakness and sensory loss (88.9%). n
Magnetic resonance imaging studies have a high false-positive rate for asymptomatic SEH. Therefore, the routine use of postoperative MRI is an impractical diagnostic tool for the detection of symptomatic SEH.1,8,9 Given that the specificity of MRI is low in the diagnosis of symptomatic SEH during the immediate postoperative period, clinicians must base their diagnosis on the patient’s symptoms and physical signs. Magnetic resonance imaging after lumbar decompression surgery frequently will identify asymptomatic SEH, however MRI is also a useful adjunct to the diagnosis and treatment of symptomatic SEH in certain situations. Specifically, MRI can be of use in patients with postoperative SEH who have questionable symptoms and no significant neural deficit (eg, a slowly evolving cauda equina syndrome, which is defined as progressive loss of function of the lumbar plexus nerve roots of the spinal canal below the termination of the spinal cord). Typically, the surgeon would prefer for an MRI to be performed to determine the location, craniocaudal extent, and compressive effect of the hematoma. The real problem with the use of MRI is that, depending on the institution, it can take multiple hours to complete and delays the start of definitive surgical treatment. Therefore, in patients who have rapidly evolving symptoms and signs of significant neurological dysfunction, especially if an MRI cannot be immediately performed, the surgeon may choose to forego MRI and proceed directly to surgery. CASE STUDY The following is a clinical case study composite of commonly seen patients experiencing symptoms of
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SEH that emphasizes the need for early recognition and treatment of postoperative symptomatic SEH. The patient’s primary care physician referred Mr C, a 28-year-old man with severe lower back and right lower extremity pain, to the surgeon. Mr C demonstrated no motor or sensory deficits on physical examination. MRI analysis showed a large, right, paracentral disc herniation compressing the S1 nerve root. The surgeon diagnosed a right S1 radiculopathy. After eight weeks of conservative management (eg, physical therapy, selective nerve root blocks) that failed to resolve the severe radicular leg pain, Mr C elected to proceed with lumbar spine surgery. The surgeon performed a right L5-S1 laminotomy and discectomy with decompression of the S1 nerve root without complication. Adequate hemostasis was achieved at the conclusion of the decompression. After standard wound closure, the OR team transferred Mr C to the postanesthesia care unit (PACU) in stable condition. Within one hour of arrival in the PACU, Mr C told the PACU nurse that he had increasing pain and numbness in his right lower extremity. Over the subsequent 15 to 30 minutes, Mr C also developed paresthesias in the left foot and the perineum. Recognizing the symptoms as atypical and indicative of neurological compromise associated with symptomatic SEH, the nurse immediately contacted the attending surgeon, who evaluated Mr C at the bedside. On physical examination, the surgeon noted that the incision site was intact, without evidence of drainage or swelling. Mr C demonstrated no muscle weakness in either lower extremity, and rectal examination demonstrated normal tone and voluntary contraction of the external anal sphincter. However, Mr C showed diminished pinprick sensation over the perineum and in the right S1 and S2 dermatomes. With a presumed diagnosis of symptomatic lumbar SEH and impending cauda equina syndrome, the surgeon decided to return Mr C immediately to surgery for exploration of the surgical site and possible hematoma evacuation. The surgeon and PACU nurse then contacted the OR nurse AORN Journal j 87
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manager, who arranged to have Mr C immediately transferred to the OR. The surgeon initiated exploration of the surgical wound less than 2.5 hours after completion of the initial procedure and identified an epidural hematoma at the L5/S1 level; he evacuated the hematoma, achieving full decompression of the caudal nerve roots. Mr C had a complete neurological and functional recovery. Sensation returned to normal within two weeks of surgery. At his six-week follow-up appointment, Mr C had no residual pain, and he returned to work in his usual occupation as a construction worker. DISCUSSION Most research regarding symptomatic SEH after lumbar spine surgery is more than a decade old. The literature remains important, however, because of the rarity of this clinical entity and the paucity of relevant published reports. Timing of Presentation and Treatment The patient in the composite case study developed symptoms associated with symptomatic SEH within one hour of completion of the initial spinal procedure.4 Amiri et al9 reported that the median time for onset of initial symptoms of SEH is 2.7 hours after surgery and the maximum neurological deficit occurs at the median time of 22.8 minutes after onset of the initial symptomatology. These findings highlight the importance of frequent monitoring, nursing assessment, and careful documentation of neurological status within the first four hours after surgery. Postoperative symptomatic SEH can have devastating effects on neurological outcomes. In a retrospective review of 3,720 patients, nine patients (0.24%) developed postoperative symptomatic SEH. After decompression, clinical outcomes revealed n
complete neurological recovery in only three of the patients (33.3%), n incomplete recovery in five of the patients (55.6%), and n no change in the neurological status of one of the patients (11.1%).7
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Generally, the patient’s neurological outcome after surgical decompression is related to the severity of preoperative neurological deficits.10 The extent of recovery also depends on the time interval from the moment of diagnosis of symptomatic SEH to the surgical decompression.11,12 In the composite case study presented in this report, the surgical team returned the patient to the OR within two to 2.5 hours of the initial surgery and one to 1.5 hours after the onset of his symptoms. This suggests that the nurse’s prompt recognition of neurological symptoms and the surgeon’s urgent surgical evacuation of the hematoma resulted in a positive outcome and complete neurological recovery. Clinical case studies support the need for urgency to decompress postoperative lumbar SEH. Cabana et al5 reported positive outcomes in eight of 10 patients with postoperative SEH if decompression surgery was performed within 1.25 to four hours of the start of the repeat decompression procedure. In patients with delayed decompression (eg, a delay of return to the operating room more than four hours from symptom onset), permanent loss of sphincter function or complete paralysis ensued. Several studies have documented a direct correlation between the extent of the neurological recovery and a short time interval from diagnosis to decompression.4,13-16 The composite case study presented in this report demonstrates that early decompression of the spinal canal has the potential to result in complete neurological recovery. Risk Factors Several studies have examined risk factors for the development of symptomatic SEH after lumbar spine surgery.2,9,17-19 Awad et al17 conducted a review of 14,932 patients who underwent spine surgery between 1984 and 2002. Preoperative risk factors for SEH were n
use of nonsteroidal anti-inflammatory drugs preoperatively, n Rh-positive blood type, and n aged 60 years or older.
DIAGNOSING AND TREATING SPINAL EPIDURAL HEMATOMA
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TABLE 1. Risk Factors for Symptomatic Spinal Epidural Hematoma Preoperative risks n n n n n n
Aged 60 years or older Alcohol consumption Use of nonsteroidal anti-inflammatory drugs Preoperative coagulopathy Previous spinal surgery Rh-positive blood group
1-3
Intraoperative risks n n n n
Blood loss > 1 L Extensive epidural space exposure Hemoglobin level < 10 g/dL Multilevel procedures
Postoperative risks n
International normalized ratio > 2.0 within the first 48 hr after surgery
1. Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila Pa 1976). 2002;27(15): 1670-1673. 2. Amiri AR Fouyas IP, Cro S, Casey AT. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J. 2013; 13(2):134-140. 3. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87(9):1248-1252.
Intraoperative risk factors for SEH included n
requiring surgical intervention on more than five spinal levels, n hemoglobin level less than 10 g/dL, and n blood loss greater than 1 L. In that same study, the researchers determined that the single postoperative risk factor for the development of symptomatic SEH was an international normalized ratio greater than 2.0 within the first 48 hours after surgery (Table 1). Another case-controlled, retrospective study conducted by Kou et al2 demonstrated that significant risk factors for the development of postoperative symptomatic SEH were multilevel procedures and preoperative coagulopathy. Amiri et al9 reported that significant risk factors for the development of postoperative SEH were preoperative alcohol intake, multilevel procedures, and previous spinal surgery. The only significant risk factor for the development of symptomatic SEH in the case study patient was an Rh-positive blood group. The patient underwent a single-level discectomy, which suggests that even relatively minor lumbar spine surgery may lead to SEH in otherwise healthy young patients.18,19
PERIOPERATIVE NURSING IMPLICATIONS Perioperative nursing personnel should be aware of the risk factors for symptomatic SEH after lumbar spine surgery as well as the timing of presentation and need for rapid treatment. Prompt and direct communication between the PACU nurse and the attending surgeon will help guide selection of appropriate interventions. This clinical case study was presented at nursing grand rounds as well as the department of orthopedic grand rounds in an effort to educate all personnel involved in the care of patients undergoing spinal surgery regarding the risk factors for and presenting symptoms of symptomatic postoperative SEH. CONCLUSION Symptomatic SEH after lumbar spine surgery can lead to serious neurological compromise. Although the reported incidence of symptomatic SEH is low compared with asymptomatic SEH, the potentially devastating consequences make prompt diagnosis and management essential. If SEH is suspected, perioperative nurses should contact the surgeon without delay. Neurological and functional recovery depends on the time interval from symptom onset to evacuation of the SEH. Early decompression of the spinal canal has the potential to result in
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complete neurological recovery. Prompt recognition and reporting by perioperative nurses can help achieve a positive clinical outcome. Editor’s note: The patient in the case study presented in this article is a composite and not representative of an actual patient. References 1. Sokolowski MJ, Garvey TA, Perl J II, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine (Phila PA 1976). 2008; 33(1):108-113. 2. Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila PA 1976). 2002;27(15):1670-1673. 3. Scavarda D, Peruzzi P, Bazin A, et al. Postoperative spinal extradural hematomas. 14 cases. Review [in French]. Neurochirurgie. 1997;43(4):220-227. 4. 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. 5. Cabana F, Pointillart V, Vital J, Senegas J. Postoperative compressive spinal epidural hematomas. 15 cases and review of the literature [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(4):335-345. 6. Johnston RA. The management of acute spinal cord compression. J Neurol Neurosurg Psychiatry. 1993; 56(10):1046-1054. 7. Yi S, Yoon DH, Kim KN, Kim SH, Shin HC. Postoperative spinal epidural hematoma: risk factor and clinical outcome. Yonsei Med J. 2006;47(3):326-332. 8. Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J. 2003; 3(2):125-129. 9. Amiri AR, Fouyas IP, Cro S, Casey AT. Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management. Spine J. 2013;13(2):134-140. 10. Foo D, Rossier AB. Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas. Surg Neurol. 1981;15(5):389-401. 11. Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am. 1995; 77(7):1042-1049. 12. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79(6):1165-1177. 13. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg. 1984;61(6):143-148.
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DANIELSdSCHIEBERTdPALUMBO 14. Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 1980;53(6):749-755. 15. Cooper DW. Spontaneous spinal epidural hematoma. Case report. J Neurosurg. 1967;26(3):343-345. 16. Payne DH, Fischgrund JS, Herkowitz HN, Barry RL, Kurz LT, Montgomery DM. Efficacy of closed wound suction drainage after single-level lumbar laminectomy. J Spinal Disord. 1996;9(5):401-403. 17. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of postoperative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87(9):1248-1252. 18. Groen RJ, Ponssen H. The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci. 1990; 98(2-3):121-138. 19. Schoenfeld AJ, Ochoa LM, Bader JO, Belmont PJ Jr. Risk factors for immediate postoperative complications and mortality following spine surgery: a study of 3,475 patients from the National Surgical Quality Improvement Program. J Bone Joint Surg Am. 2011;93(17):1577-1582.
Alan H. Daniels, MD, is a clinical instructor in the orthopedic department at Rhode Island Hospital, Providence. Dr Daniels has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Steven S. Schiebert, DO, is a clinical instructor in the orthopedic department at Rhode Island Hospital, Providence. Dr Schiebert has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Mark A. Palumbo, MD, is an associate professor of spine surgery in the orthopedic department at Rhode Island Hospital, Providence. Dr Palumbo has declared financial relationships with Stryker, Kalamazoo, MI, and Globus Medical, Audubon, PA, as a consultant and lecturer and also with a variety of law firms as an expert witness, which could be perceived as posing potential conflicts of interest in the publication of this article.
EXAMINATION
1.1
CONTINUING EDUCATION
www.aorn.org/CE Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills
PURPOSE/GOAL To provide the learner with knowledge specific to rapid identification and treatment of postoperative symptomatic spinal epidural hematoma (SEH) after lumbar spine surgery.
OBJECTIVES 1. 2. 3. 4.
Discuss diagnosis of postoperative symptomatic SEH. Explain the presentation of symptomatic SEH. Describe complications of postoperative symptomatic SEH. Identify risk factors for developing symptomatic SEH.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
Most spinal epidural hematomas (SEHs) that occur after lumbar spine surgery are asymptomatic. a. true b. false The clinical presentation of acute-onset SEH is described as the patient developing severe pain at the level of surgery followed by development of one or more of the following complications: 1. bladder dysfunction. 2. lethargy and confusion. 3. lower extremity motor weakness and subsequent sensory loss. 4. lower extremity radicular pain. a. 1 and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
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3.
Magnetic resonance imaging (MRI) scans have a high true-positive rate for asymptomatic SEH; therefore, routine postoperative MRI is advisable. a. true b. false
4.
Clinicians must base the diagnosis of symptomatic SEH during the immediate postoperative period on 1. a routine MRI. 2. a lumbar puncture. 3. the patient’s clinical symptoms. 4. the physical examination. a. 1 and 2 b. 3 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
5.
Acute loss of function of the lumbar plexus nerve roots of the spinal canal below the termination of the spinal cord is called a. cauda equina syndrome.
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CE EXAMINATION
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b. conus medullaris syndrome. c. spastic paraplegia with Kallmann syndrome. d. tethered spinal syndrome. 6.
The median time for onset of initial symptoms of SEH is ________ hours after surgery. a. 1.2 b. 1.7 c. 2.2 d. 2.7
7.
In a retrospective review of 3,720 patients, nine patients developed postoperative SEH, of which 1. 11.1% had no change in their neurological status. 2. 33.3% achieved complete neurological recovery. 3. 55.6% achieved incomplete recovery. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
8.
Generally, the patient’s neurological outcome after surgical decompression is related to the 1. patient’s age (ie, those older than 50 years of age have an increased risk of poor outcome). 2. severity of preoperative neurological deficits. 3. time interval from the moment of diagnosis of symptomatic SEH to the surgical decompression.
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4.
placement of a surgical drain at the conclusion of the surgery. a. 1 and 4 b. 2 and 3 c. 1, 2, and 4 d. 1, 2, 3, and 4
9.
In a review of 14,932 patients, preoperative risk factors for SEH were 1. symptom onset more than three years previously. 2. Rh-positive blood type. 3. use of nonsteroidal anti-inflammatory drugs. 4. use of opioid narcotics before surgery. 5. age of 60 years or older. a. 1 and 4 b. 2 and 5 c. 2, 3, and 5 d. 1, 2, 3, 4, and 5
10.
Researchers determined that the single postoperative risk factor for symptomatic SEH was a. an international normalized ratio greater than 2.0 within the first 48 hours after surgery. b. a hemoglobin level less than 10 g/dL. c. blood loss greater than 1 L. d. a required surgical procedure on more than two operative levels.
LEARNER EVALUATION
1.1
CONTINUING EDUCATION PROGRAM
www.aorn.org/CE Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http:// www.aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss diagnosis of postoperative symptomatic spinal epidural hematoma (SEH). Low 1. 2. 3. 4. 5. High 2. Explain the presentation of symptomatic SEH. Low 1. 2. 3. 4. 5. High 3. Describe complications of postoperative symptomatic SEH. Low 1. 2. 3. 4. 5. High 4. Identify risk factors for developing symptomatic SEH. Low 1. 2. 3. 4. 5. High CONTENT 5. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 6. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 7. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
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8. Will you change your practice as a result of reading this article? (If yes, answer question #8A. If no, answer question #8B.) 8A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other:________________________________ 8B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 9. Our accrediting body requires that we verify the time you needed to complete the 1.1 continuing education contact hour (66-minute) program: ________________________________
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