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Naoki Ishiguro - One of the best experts on this subject based on the ideXlab platform.
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Acute non-traumatic idiopathic Spinal subdural Hematoma: radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:Purpose IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. Methods All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Results Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Conclusions Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
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acute non traumatic idiopathic Spinal subdural Hematoma radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
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Delayed Onset of Subdural Hematoma following Epidural Catheter Breakage
Global Spine Journal, 2015Co-Authors: Yoshimoto Ishikawa, Shiro Imagama, Zenya Ito, Kei Ando, Momokazu Gotoh, Kimitoshi Nishiwaki, Yoshimasa Nagao, Naoki IshiguroAbstract:Study Design Case report. Objectives To describe a case of delayed-onset Spinal Hematoma following the breakage of a Spinal epidural catheter. Methods The authors describe the clinical case review. Results A 64-year-old woman had undergone epidural anesthesia 18 years before she was referred to our hospital because of lower-back pain and lower neurologic deficit with leg pain. The clinical examination showed the presence of a fragment of an epidural catheter in the thoracolumbar canal, as assessed by computed tomography, and a Spinal Hematoma that compressed the Spinal cord at the same Spinal level, as assessed by magnetic resonance imaging. Surgical removal of the epidural catheter and decompression surgery were performed. The patient exhibited substantial clinical improvement 1 month after surgery; she achieved a steady gait without the need for a cane and had no leg pain. Conclusion This is the first report of delayed onset of Spinal Hematoma following the breakage of an epidural catheter. Generally, when the breakage of an epidural catheter occurs without symptoms, follow-up alone is recommended. However, because Spinal Hematoma might exhibit a late onset, the possibility of this complication should be considered when deciding whether to remove the catheter fragment. We believe that in our patient, there could be a relationship between the catheter fragment and subdural Hematoma, and catheter breakage could have been a risk factor for the Spinal Hematoma.
Terese T. Horlocker - One of the best experts on this subject based on the ideXlab platform.
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Blood and Pus: Hemorrhagic and Infectious Complications of Neuraxial Anesthesia
2011Co-Authors: Terese T. HorlockerAbstract:Spinal Hematoma The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown; however, recent epidemiologic studies suggest the incidence is increasing (1). In a review of the literature between 1906 and 1994, Vandermeulen et al. (2) reported 61 cases of Spinal Hematoma associated with epidural or Spinal anesthesia. In 87% of patients, a hemostatic abnormality or traumatic/difficult needle placement was present. More than one risk factor was present in 20 of 61 cases. Importantly, although only 38% of patients had partial or good neurologic recovery, Spinal cord ischemia tended to be reversible in patients who underwent laminectomy within eight hours of onset of neurologic dysfunction. It is impossible to conclusively determine risk factors for the development of Spinal Hematoma in patients undergoing neuraxial blockade solely through review of the case series, which represent only patients with the complication and do not define those who underwent uneventful neuraxial analgesia. However, large inclusive surveys that evaluate the frequencies of complications (including Spinal Hematoma), as well as identify subgroups of patients with higher or lower risk, enhance risk stratification. In the series by Moen et al. (3) involving nearly 2 million neuraxial blocks, there were 33 Spinal Hematomas. The methodology allowed for calculation of frequency of Spinal Hematoma among patient populations. For example, the risk associated with epidural analgesia in women undergoing childbirth was significantly less (1 in 200,000) than that in elderly women undergoing knee arthroplasty (1 in 3600, p
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Locoregional anesthesia and anticoagulation
European Journal of Pain Supplements, 2009Co-Authors: Terese T. HorlockerAbstract:Abstract Spinal Hematoma is a rare and potentially catastrophic complication of Spinal or epidural anesthesia. Risk factors include traumatic needle/catheter placement, sustained anticoagulation in an indwelling neuraxial catheter, and catheter removal during therapeutic levels of anticoagulation. Generally, a patient’s coagulation status should be optimized at the time of Spinal or epidural needle/catheter placement, and the level of anticoagulation should be monitored during epidural catheterization. Signs of cord compression, such as severe back pain, progression of numbness or weakness, and bowel and bladder dysfunction, warrant immediate radiographic evaluation. A delay in diagnosis and intervention of Spinal Hematoma may lead to irreversible cord ischemia.
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Recommendations for Anticoagulated Patients Undergoing Image-Guided Spinal Procedures
American Journal of Neuroradiology, 2006Co-Authors: Kennith F. Layton, David F. Kallmes, Terese T. HorlockerAbstract:Anticoagulated patients often need image-guided Spinal procedures for CSF harvest, myelography, vertebroplasty, vertebral biopsies, or epidural injections. The risk of Spinal Hematoma is increased in anticoagulated patients who undergo lumbar puncture or neuraxial anesthesia. Any procedure involving
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Analgesia without paraplegia: Neuraxial anesthesia and anticoagulation
2006Co-Authors: Terese T. HorlockerAbstract:An understanding of the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and also the clinical studies involving patients undergoing central neural blockade while receiving these medications is paramount in reducing the risk of Spinal Hematoma in patients undergoing neuraxial blockade. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 Spinal anesthetics (Tryba, 1993). In a review of the literature between 1906 and 1994, Vandermeulen et al (Vandermeulen, 1994). reported 61 cases of Spinal Hematoma associated with epidural or Spinal anesthesia. Included were five parturients and four patients with anatomic abnormalities of the spine, such as spina bifid occulta, Spinal ependymoma, and Spinal angioma. A Spinal anesthetic was performed in 15 cases, the remaining received an epidural technique. In 42 of the 61 patients (68%), the Spinal Hematoma occurred in patients with evidence of hemostatic abnormality. Twenty-five patients had received intravenous heparin (18 patients), subcutaneous heparin (3 patients), or LMWH (4 patients), while an additional five patients presumably received heparin during a vascular surgical procedure. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran 70 immediately before or after the neuraxial anesthetic. Needle placement was reported as difficult in 25% of patients and/or bloody in 25% of patients. Multiple punctures were reported in 20% of patients. Therefore, in 87% of patients, a hemostatic abnormality or traumatic/difficult needle placement was present. More than one Analgesia without paraplegia: Neuraxial anesthesia and anticoagulation
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Regional Anesthesia and Anticoagulation in Patients undergoing Cardiothoracic and Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia, 2003Co-Authors: Terese T. HorlockerAbstract:Spinal Hematoma is a rare and potentially catastrophic complication of Spinal or epidural anesthesia. The decision to perform Spinal or epidural anesthesia or analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, though definite risk of Spinal Hematoma with the benefits of regional anesthesia for a specific patient. Alternative anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The patient's coagulation status should be optimized at the time the Spinal or epidural needle or catheter is placed, and the level of anticoagulation must be carefully monitored during the period of epidural catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of Spinal Hematoma. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention.
Kazuyoshi Kobayashi - One of the best experts on this subject based on the ideXlab platform.
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Acute non-traumatic idiopathic Spinal subdural Hematoma: radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:Purpose IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. Methods All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Results Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Conclusions Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
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acute non traumatic idiopathic Spinal subdural Hematoma radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
Denise J. Wedel - One of the best experts on this subject based on the ideXlab platform.
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neuraxial block and low molecular weight heparin balancing perioperative analgesia and thromboprophylaxis
Regional Anesthesia and Pain Medicine, 1998Co-Authors: Terese T. Horlocker, Denise J. WedelAbstract:The efficacy and safety of low-molecular-weight heparins (LMWH) as postoperative venous thromboembolism prophylaxis has been demonstrated in more than 60 clinical trials, including more than 20,000 patients (1). However, recent reports of Spinal Hematoma occurring spontaneously and in association with regional anesthesia (2,3) have generated concern regarding the safety of Spinal or epidural anesthesia in patients receiving LMWH. This review will discuss the chronology of events leading to the current situation, as well as examine the possible factors contributing to the increased risk of Spinal Hematoma in patients receiving LMWH. heparin, significant anti-Xa activity is still present 12 hours after injection. The clearance of LMWH is primarily renal. The plasma half-life of LMWH is approximately two to four times longer than that of standard heparin and increases in patients with renal failure. The anticoagulant effects of standard heparin are neutralized by an equimolar dose of protamine. Because of the reduced protamine binding to LMWH fractions, only the anti-IIa activity of LMWH is completely reversed, whereas anti-Xa activity is not fully neutralized.Both anti-IIa and anti-Xa activity may return up to 3 hours after protamine reversal, possibly because of tile release of additional LMWH from the subcutaneous depot (22).
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Regional anesthesia in the anticoagulated patient: Yes or no
Seminars in Anesthesia Perioperative Medicine and Pain, 1998Co-Authors: Terese T. Horlocker, Denise J. WedelAbstract:PINAL Hematoma is a rare and potentially catastrophic complication of Spinal or epidural anesthesia. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 Spinal anesthetic cases. 1 Hemorrhage into the Spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. Although hemorrhagic complications can occur after virtually all regional anesthetic techniques, bleeding into the 'Spinal canal is perhaps the most serious hemorrhagic complication associated with regional anesthesia because the Spinal canal is a concealed and-nonexpandable space. Spinal cord compression from Spinal Hematoma may result in nenrologic ischemia and paraplegia. Spinal Hematoma may occur due to vascular trauma from needle or catheter placement into the subarachnoid or epidural space (Fig 1). However, it also may occur in association with neoplastic disease or pre-existing vascular abnormalities. Of special interest to the anesthesiologist are those Spinal Hematomas that have occurred spontaneously with or without the presence of antiplatelet or anticoagulation therapy. Over 100 spontaneous epidural Hematomas have been reported, 25% of which are associated with anticoagulation therapy. 2 In a review of the reports appearing in the literature between 1906 and 1994, Vandermeulen et al 3 discussed 61 cases of Spinal Hematoma associated with epidural or Spinal anesthesia. In 42 of the 61 (68%) patients, the Spinal Hematomas associated with central neural blockade occurred in patients with evidence of hemostatic abnormality. Twenty-five of the patients had received intravenous or subcutaneous heparin; as they were undergoing a vascular surgical procedure, an additional five patients were presumably administered heparin. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran 70 immediately before or after the Spinal or epidural anesthetic. Needle and catheter placement was reported to be difficult in 15 (25%) or bloody in 15 (25%) patients. Thus, in 53 of the 61 (87%) cases, either a clotting abnormality or needle placement difficulty was present. To reduce the risk of Spinal Hematoma associated with central neural blockade, it is necessary to understand the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and the clinical studies involving patients undergoing central neural blockade while receiving these medications. While this discussion will deal mainly with continuous techniques of major conduction blocks and anticoagulants, the same principles apply to all regional anesthetic techniques.
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preoperative antiplatelet therapy does not increase the risk of Spinal Hematoma associated with regional anesthesia
Anesthesia & Analgesia, 1995Co-Authors: Terese T. Horlocker, Denise J. Wedel, Darrell R Schroeder, Steven H Rose, Beth A Elliott, Diana G Mcgregor, Gilbert Y WongAbstract:One thousand orthopedic procedures in 924 patients given Spinal or epidural anesthesia were prospectively studied to determine the risk of hemorrhagic complications associated with regional anesthesia.A history of excessive bruising or bleeding was elicited in 115 (12%) patients. Preoperative antipl
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Postoperative epidural analgesia and oral anticoagulant therapy.
Anesthesia & Analgesia, 1994Co-Authors: Terese T. Horlocker, Denise J. Wedel, Joyce L. SchlichtingAbstract:The relative safety of epidural catheter placement with subsequent heparinization has been well documented. However, what is the risk of neurologic sequelae in such patients who receive warfarin perioperatively? This study retrospectively evaluates the risk of Spinal Hematoma in patients receiving postoperative epidural analgesia while receiving low-dose warfarin after total knee replacement. All patients received low-dose warfarin to prolong the prothrombin time (PT) to 15.0-17.3 s (normal 10.9-12.8 s). There were 192 epidural catheters placed in 188 patients. All catheters were advanced through an 18-gauge needle. In 13 instances, blood was noted during needle and/or catheter placement. In addition to warfarin, 36 patients with indwelling catheters received nonsteroidal antiinflammatory drugs (NSAIDs). Epidural catheters were left indwelling 37.5 +/- 15 h (range 13-96 h). The mean PT was not increased beyond the normal range until the third postoperative day and did not reach 15 s until the seventh postoperative day. Cumulative warfarin dose at that time was 20.0 +/- 7.6 mg. Mean PT at the time of epidural catheter removal was 13.4 +/- 2 s. There were no signs of Spinal Hematoma. Although epidural catheter placement and subsequent anticoagulation with warfarin appears relatively safe, there is a large variability in patient response to warfarin; therefore, coagulation status should be monitored to avoid excessive prolongation of the PT, and the patient should be watched closely for evidence of Spinal Hematoma.
Kei Ando - One of the best experts on this subject based on the ideXlab platform.
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Acute non-traumatic idiopathic Spinal subdural Hematoma: radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:Purpose IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. Methods All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Results Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Conclusions Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
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acute non traumatic idiopathic Spinal subdural Hematoma radiographic findings and surgical results with a literature review
European Spine Journal, 2017Co-Authors: Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Yoshihiro Nishida, Naoki IshiguroAbstract:IntraSpinal Hematoma is a serious condition, and early diagnosis is necessary to permit emergency treatment. Among such Hematomas, non-traumatic Spinal subdural Hematoma is a rare occurrence. We have experienced three patients with surgically proven subdural Spinal Hematoma, and here we report these cases with a review of their clinical and imaging characteristics. All three cases were idiopathic with no history of disease, no coagulopathy, and no trauma. All had acute onset that brought about paralysis of the lower limbs with severe pain. Early surgery was performed, based on a relatively early diagnosis using thoracolumbar MRI and CT. Since the epidural fat is not affected by bleeding, the normal structure remains and the boundary between Hematoma and fat is a significant feature in MRI and CT. Partial Gd enhancement in MRI and ring enhancement in contrast CT were also apparent. Two of the cases had subarachnoid Hematomas. Preoperative diagnosis of Spinal subarachnoid Hematoma is difficult because there are no specific radiological findings and confirmation can only occur intraoperatively. In particular, one case had a massive Hematoma causing canal stenosis, and it was difficult to distinguish between intradural and extradural Hematoma. In all cases of subarachnoid or subdural Hematoma, decompression was performed within 24 h after onset, and consequently, the patients had relatively good outcomes.
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Delayed Onset of Subdural Hematoma following Epidural Catheter Breakage
Global Spine Journal, 2015Co-Authors: Yoshimoto Ishikawa, Shiro Imagama, Zenya Ito, Kei Ando, Momokazu Gotoh, Kimitoshi Nishiwaki, Yoshimasa Nagao, Naoki IshiguroAbstract:Study Design Case report. Objectives To describe a case of delayed-onset Spinal Hematoma following the breakage of a Spinal epidural catheter. Methods The authors describe the clinical case review. Results A 64-year-old woman had undergone epidural anesthesia 18 years before she was referred to our hospital because of lower-back pain and lower neurologic deficit with leg pain. The clinical examination showed the presence of a fragment of an epidural catheter in the thoracolumbar canal, as assessed by computed tomography, and a Spinal Hematoma that compressed the Spinal cord at the same Spinal level, as assessed by magnetic resonance imaging. Surgical removal of the epidural catheter and decompression surgery were performed. The patient exhibited substantial clinical improvement 1 month after surgery; she achieved a steady gait without the need for a cane and had no leg pain. Conclusion This is the first report of delayed onset of Spinal Hematoma following the breakage of an epidural catheter. Generally, when the breakage of an epidural catheter occurs without symptoms, follow-up alone is recommended. However, because Spinal Hematoma might exhibit a late onset, the possibility of this complication should be considered when deciding whether to remove the catheter fragment. We believe that in our patient, there could be a relationship between the catheter fragment and subdural Hematoma, and catheter breakage could have been a risk factor for the Spinal Hematoma.