Delayed Epidural Hematomas after Spinal Surgery

Introduction: Symptomatic epidural hematomas after spinal surgery are uncommon and are usually diagnosed within 24 hours after surgery. The contribution of an extradural hematorna to pain or a new neurological deficit recognized immediatly after surgery is often questioned as post–operative imaging after spinal surgery will frequently demonstrate some blood at the surgical site. We present a series of delayed spinal epidural hematomas, in a subset of patients who awoke from surgery neruologically unchanged, and then deteriorated more than 3 days after their index procedure.

Methods: We retrospectively reviewed our data base over a 3 year period (1996–1999). We examined potential risk factors for spinal extradural hematomas including medical conditions and medications which predispose to bleeding, coagulation studies, the use and timing of drains and previous surgery.

Results: The average "asymptomatic" period after initial surgery was 5.5 days for the 6 cases. The index procedure was a posterior approach in all cases and included cervical laminoplasty (n=2), cervicothoracic fusion (n=l), thoracic laminectomy for dural avm (n=1) and posterolateral approach for a lateral thoracic disc (n=2). Drains were used in 2/6 patients. The clinical picture consisted of a new onset of intense local incisional pain associated with paraesthesias, sensory loss and motor weakness. Clinical suspicion was confirmed by emergent MRI and prompt decompression resulted in neurologic recovery in all but one patient.

Conclusions: Delayed spinal epidural hematomas are rare (0.25%). Multiple potentiating factors for the development of a delayed spinal epidural hematomas were recognized and included; hepatitis C (n=2), thrombocytopenia (n=l), aspirin and toradol use (n=l) and full heparinization (n=l). Surgery undertaken within the boundaries of a previous incision (re–do) impairs clot resorption and may be a previously unrecognized factor for the development of a delayed hematoma.