Spinal subarachnoid hematoma after spinal anesthesia

Corresponding author: Sang Lee Park, M.D., Department of Anesthesiology and Pain Medicine, National Police Hospital, Garakbon-dong, Songpa-gu, Seoul 138-708, Korea. Tel: 82-2-3400-1325, Fax: 82-2-3400-1322, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Moen et al. [1] reported that spinal hematoma occurred in 8 out of 1,260,000 cases of spinal anesthesia in Sweden, and subarachnoid hematoma is known to be very rare [2]. We report a case of subarachnoid hematoma after spinal anesthesia in a patient without coagulopathy. A 33-year-old man with a height of 170 cm and weight of 65 kg underwent emergency surgery for acute appendicitis without perforation. The patient had no specific medical history and was taking no medications. Preoperative laboratory examinations including platelet count (236,000/mm), prothrombin time (12.2 seconds, with international normalized ratio 1.07), and activated partial thromboplastin time (29.5 seconds) were in the normal range. The patient was placed in the right lateral decubitus position, and spinal anesthesia was attempted at the L4-5 intervertebral space via a midline approach using a 25 G Quincke spinal needle (Hakko Co., Naganoken, Japan). On the first trial, the needle reached the spinous process before it passed the ligamentum flavum, so it was removed immediately. On the second trial, clear cerebrospinal fluid without blood was observed without any particular difficulties. Fourteen milligrams of 0.5% hyperbaric bupivacaine mixed with fentanyl 15 μg was injected without pain, numbness, or dysesthesia. The patient was placed in the supine position, and the level of sensory block was T7 at 5 minutes after intrathecal injection. The operation was uneventful, and he was discharged without any specific neurologic symptoms. Five days after the spinal anesthesia, the patient called complaining of lower back pain and numbness in the lower limbs without allodynia, hypoesthesia, or paralysis. The complications that can occur after spinal anesthesia, such as transient neurologic symptoms (TNS), hematoma, abscess, cauda equina syndrome, spinal neurological damage, muscle rigidity, and myofascial pain, were explained to the patient, and he was asked to come to the hospital. However, the patient wanted to go to another hospital because of his personal affairs. Magnetic resonance imaging performed at the other hospital showed the presence of a subarachnoid hematoma (Fig. 1). The patient was mornitored closely but received no other treatment because the lesion was not large and his symptoms were improving. Ten days after the spinal anesthesia, his symptoms had all resolved. Spinal subarachnoid hematoma cases reported up to now have occurred mostly in patients who had problems with blood coagulability or in instances when anticoagulant was admini-