Susan C. Harvey, MD et al. (1) from the Medical University of South Carolina, Charleston, South Carolina, reported recently a case of spinal epidural hematoma detected by lumbar epidural puncture. A 75 year old patient underwent femoral-distal bypass to the posterior tibial artery under epidural anesthesia. On the 10th postoperative day, he again complained of left foot pain. Repeat arteriography revealed flow-limiting stenosis above the distal anastomosis. An epidural anesthetic was once again planned. Coagulation variables were within normal limits. When an 18-gauge Tuohy needle was inserted at the L3-4 level, black, tarry, liquefied blood returned under pressure from the epidural space.After removal of approximately 10 ml of old blood, no additional blood returned passively or with gentle aspiration. The needle was withdrawn, and the anesthetic technique was converted to a spinal anesthetic at the L2-3 interspace. The surgery proceeded uneventfully.Computerized tomography (CT) without contrast was performed postoperatively. The CT scan was equivocal for the presence of epidural hematoma. Subsequent magnetic resonance imaging (MRI) revealed epidural hematoma at interspace L2-4. The patient remained neurologically intact and was discharged on the sixth postoperative day.

1. Harvey SC, Roland PJ, Cure JK, Cuddy BG, O`Neil MG. Spinal epidural hematoma detected by lumbar epidural puncture.Anesth Analg 1997;84:1136-9

Almost a year and a half ago I have suggested in the Gasnet Discussion Group that evacuation of epidural hematoma by an epidural needle and/or catheter is a clinical option before any operation.

The case report by Harvey et al. shows that it is not only possible but it should be the first immediate treatment in every case suspected of developing an epidural hematoma.

As always, Mark Twain is correct: "Name the greatest of all the inventors. Accident"...

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Joseph Eldor, MD
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Case report:
A 24 year old parturient requested an epidural analgesia for labor. The
anesthesiologist advised her a "walking" epidural using the combined
spinal-epidural technique. Blood pressure was 110/80 mmHg and pulse - 100
beats/min. The patient received 1,000 ml Lactated Ringer`s solution before
starting the procedure. Lying on her right side at the "epidural position"
an 18G Eldor needle (Alexander Medical Inc.,Coral Springs, FL) was inserted
at the L2-3 interspace. After identification of the epidural space an
epidural catheter 20G was inserted and tested by 3 ml lidocaine 2%. Two
minutes later a 26G Double-hole pencil point spinal needle (DHPP), which is
an integral part of the Eldor needle minipack, was inserted through the
spinal conduit of the Eldor needle into the subarachnoid space. After the
appearance of CSF at the hub of the spinal needle fentanyl 15 microgram were
injected through the spinal needle. Then the spinal needle was withdrawn and
afterwards the Eldor needle leaving the epidural catheter in the epidural
space. The patient had a good analgesia during contractions and could move
her legs as before. One hour and a half later the patient had an almost pain
free vaginal delivery. Half an hour later the patient complained of
inability to move both legs. An epidural hematoma was suspected and the
patient was taken immediately to the CT scan where the diagnosis was proved.
At the CT scan the patient was lain on her right side at the epidural
position and an 18G epidural needle was inserted into the subarachnoid space
at the L1-2 interspace. An epidural catheter was inserted through it
evacuating a bloody CSF.Another 18G epidural needle was inserted into the
epidural space at the L3-4 interspace evacuating also blood at the range of
20-30 ml. Another epidural catheter was left also in the epidural space.
Five minutes later the patient could move both her legs. She was supervised
at the intensive care unit for two days with no return of the paralysis. The
catheters were withdrawn at the second day post delivery. The patient was
discharged from the hospital two days later.

This case report didn`t happen. It serves for the description of a potential
treatment for epidural hematoma - evacuation of blood by an epidural needle
and catheter in the epidural and subarachnoid spaces.
Comments are invited.