How do I manage a spinal epidural hematoma?

Nursing, Apr 2003 by Wall, Norma J

CLINICAL QUERIES

Following a total abdominal hysterectomy, my 50-year-old patient received a continuous epidural infusion of hydromorphone (Dilaudid) for pain management. At the beginning of my shift, she complained of discomfort at the catheter insertion site, but I found no signs of edema or ecchymosis. Two hours later, she complained of severe lower back pain and weakness and numbness in her left foot and leg. Assessing her, I found she had unilateral weakness of the left leg with motor strength of 3/5 and diminished sensation to light touch and pain via pinprick. I immediately notified the anesthesia provider, who said she had a traumatic spinal epidural hematoma and ordered stat magnetic resonance imaging (MRI).

I've never seen this complication before. Why did it happen? -C.L., TEX.

Norma J. Wall, RN,C, WHNP, MSN, replies: A spinal epidural hematoma is a very rare but serious complication of epidural analgesia. When blood accumulates between the spinal dura and bone, it compresses nerves. If not treated promptly, it can cause permanent neurologic deficits.

A spinal epidural hematoma may occur spontaneously or follow minor trauma, such as lumbar puncture or epidural anesthesia. Other risk factors include preoperative or postoperative anticoagulation, coagulopathies, vascular malformation, thrombolysis, thrombocytopenia, advanced age, and neoplasms.

Signs and symptoms, which are related to the level of hematoma formation, may include severe localized back pain; unilateral or bilateral weakness, numbness, or other sensory deficits; hemiplegia or paraplegia; urine retention or incontinence; and fecal incontinence. Signs and symptoms also may mimic anatomic spinal cord syndromes.

Assess the patient's respiratory status and motor function. Test your patient's muscle strength (of the major muscle groups) by asking her to resist your movement oi to move actively against your resistance. if her muscles are too weak to overcome resistance, test them against gravity.

Then assess her sensory function, starting with the toes and moving upward on the body to evaluate all dermatomes. Compare corresponding areas on both sides of her body. Assess proprioception.

Tell the patient to stay in bed and make sure she can reach the call bell. Report your assessment findings to the anesthesia provider and primary care provider immediately.

Prepare the patient for stat MRI or computed tomography myelography to confirm the presence of a hematoma and evaluate the extent of bleeding. Be ready to assist with removal of the epidural catheter. The anesthesia provider may wish to send the epidural catheter and medication bag for further testing (for example, to confirm that the correct medication was given or to rule out infection), so have appropriate collection materials for your lab.

Occasionally, spinal epidural hematomas resolve on their own. However, most need to be evacuated surgically. Surgery should take place within 12 hours of symptom onset for the best chance of full neurologic recovery. The longer surgery is delayed, the greater the chance of permanent neurologic disability.

Depending on the extent of neurologic injury, the patient may later need inpatient and outpatient physical and occupational therapy.

SELECTED REFERENCES

Kou, J., et al.: "Risk Factors for Spinal Epidural Hematoma After Spinal Surgery." Spine, 27(15):1670-1673. August 1, 2002.

Stoll, A., and Sanchez, M.: "Epidural Hematoma After Epidural Block: Implications for Its Use in Pain Management." Surgical Neurology, 57(4):235-240. April 2002.

Norma J. Wall is an instructor in clinical nursing at Vanderbilt University School of Nursing in Nashville, Tenn. Clinical Queries is coordinated by Joan E. King, RN,C, ACNP, ANP, PhD, program director for the acute care nurse practitioner program at Vanderbilt University.