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CHRONIC SUBDURAL HAEMATOMA FOLLOWING SPINAL ANAESTHESIA - A Case Report Dr. D. Saha1 Dr. S. Swaika2 Dr. D. Bhattacharya3 Dr. Thomas Joseph4 Dr. P. Mukherjee5 SUMMARY Subdural haematoma is a serious but rare complication after spinal anaesthesia and is thought to be preventable by prompt treatment with an epidural blood patch. A 47 year old lady was operated for abdominal hysterectomy under spinal anaesthesia. It was uneventful. Twenty eight hours after the spinal anaesthesia, she developed a typical post dural puncture headache, which increased in severity over the subsequent 24 hours. She was treated with bed rest, analgesics and epidural blood patch, which initially relieved the headache. After discharge from hospital, 20 days later she developed headache and vomiting, not responding to bed rest and analgesia. A Computerised Tomography Scan demonstrated a left temporoparietal chronic subdural haematoma with 11 mm midline shift, which was drained successfully with complete recovery.
Keywords : Spinal anaesthesia complications; Headache, Subdural haematoma. Introduction Subdural haematoma (SDH) is a well documented but rare complication of dural puncture. Cases have been reported following accidental dural puncture with an epidural needle, and also after spinal anaesthesia, myelography, discography and diagnostic lumbar puncture. Few anecdotal cases of this neurological complication are described in the literature.1,2 We report a case of chronic SDH in a patient who underwent abdominal hysterectomy under spinal anaethesia. Case report A 47 year old lady present with fibroid uterus for abdominal hysterectomy. After preanaesthetic checkup she was found to be ASA grade I, height 1.55 metres and weighing 62 kgs. Her baseline investigations were within normal limits. Abdominal hysterectomy was planned under 1. M.D., Asst. Prof. 2. M.D., Asst. Prof. 3. M.D., DNB Asso. Prof. 4. Mch., Consultant Neuro Surgeon 5. M.D., Asso. Prof. 1,2.Dept. of Anaesthesiology 3,5.Dept. of Gynaecology and Obstetrics Burdwan Medical College and Hospital Burdwan, West Bengal 4. Chittaranjan Advanced Medical Research Institute, Burdwan, West Bengal. Correspond to : Dr. Debasish Saha Baburbagh Doctors Qtrs. No. 16, Block - III Burdwan Medical College, Burdwan – 713101 West Bengal, India. E-mail :
[email protected] (Accepted for publication on 29-05-2004)
spinal anaesthesia. She was pre loaded with ringer’s lactate solution 800 ml before spinal anaesthesia. Under strict aseptic precautions a 23G Quinckie needle was introduced at L4-5 interspace and 3 ml of 0.5% heavy bupivacaine was injected after the first attempt of dural puncture. She remained haemodynamically stable throughout, during and after the surgery. She was apparently well after the initial surgery for a period of 28 hours, when she developed frontal headache which was throbbing in nature associated with nausea and vomiting which exaggerated when mobilized. She was managed conservatively by maintaining supine position, oral analgesics and increased intake of fluids. Forty eight hours later an epidural blood patch was performed at L3-4 space. She was in the hospital for the next 5 days and was discharged home with total relief from headache. She was well for then next three weeks and again developed headache and vomiting which was not relived with any medication. There was no h/o loss of consciousness, seizures, limb weakness or dysphasia. Symptoms worsened and the physician referred the case to a Neurosurgeon. CT scan revealed left temporoparietal chronic SDH with 11 mm midline shift. A craniotomy was performed and the clot was evacuated. Post-operative period was uneventful. Discussion Owing to similarity of symptoms with post dural puncture headache (PDPH), the diagnosis of chronic subdural haematoma (SDH) is difficult in clinical practice. Bier was the first person to report post dural puncture headache following spinal anaesthesia in 1898 and suggested cerebro spinal fluid (CSF) leak as its possible cause.3 In 1943 Kunkle et al explained that CSF leak causes a sudden decrease in intracranial pressure allowing the brain and meninges to sag. It results in traction of pain sensitive vascular structures
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producing headache particularly in upright position.4 PDPH is a major disadvantage of spinal anaesthesia. Its incidence is related to needle size, type of needle, direction of the bevel and patient’s age. Traction combined with vasodilatation, occasionally results in tearing of the veins producing SDH, either unilateral or bilateral.5 Vos et al reported two cases of large SDH, which required surgical evacuation.6 The treatment of PDPH was first introduced by Gromely in 1960 with an epidural blood patch.7 Unlike PDPH, the striking clinical feature of SDH is severe headache even in the recumbent position.8 The efficacy and benefit of prophylactic versus therapeutic blood patch in gynaecological and obstetrical patients is speculative, and prospective randomized comparative study would be needed to address this question. Our case report and other publication9 suggest that one can not really rely on an epidural blood patch to prevent the development of a SDH, when the patch is performed after the onset of the symptoms of a CSF leak. Failure to recognize these rare cases of SDH can have permanent and fatal consequences.
regional anaesthetic risks. So, the dictum should be “Always Alert – Accident Avert.”
Therefore, it is important to investigate persistent or recurrent headache, particularly those associated with neurological signs, and a CT or MRI Scan should be performed appropriately. Whilst an epidural blood patch usually provides almost instantaneous relief for PDPH, its long term efficacy is probably only 60–70%.10 This case suggests that an epidural blood patch, contrary to popular belief, may not provide full protection against devastating complication of a dural puncture. Anticipation and prevention of complications, along with their early diagnosis and treatment are the most important factors in dealing with
7. Gormley JB. Treatment of post spinal headache. Anesthesiology 1960; 21: 565–566.
References 1. Acharya R, Chhabra SS, Ratra M, Sehgal AD. Cranial subdural haematoma after spinal anaesthesia. Br J Anaesth 2001; 86: 893-895. 2. Thorsen G. Neurological complications after spinal anaesthesia and results from 2, 493 follow up cases. Acta Chir Scand 1947; 95: 265-268. 3. Reynolds F. Dural puncture and headache: avoid the first but treat the second. BMJ 1993; 306: 874-876. 4. Brownridge P. The management of headache following accidental dural puncture in obstetric patients. Anaesth Intens Care 1983; 11: 4-15 5. Stocks GM, Wooller DJA, Young JM et al. Postpartum headache after epidural blood patch: investigation and diagnosis. Br J Anaesth 2000; 84: 407-410. 6. Vos PE, De Boer WA, Wurzer JA, Van Gjin J. Subdural hematoma after lumbar puncture: two case reports and review of the literature. Clin Neurol Neurosurg 1991; 93: 127-132.
8. Macon ME, Armstrong L, Brown EM. Subdural haematoma following spinal anaesthesia. Anesthesiology 1990; 72: 380-381. 9. Davies JM, Murphy A, Smith M, Sullivan G. Subdural haematoma after lumbar puncture treated by epidural blood patch. Br J Anaesth 2001; 86: 720-723. 10. Williams EJ, Beaulieu P, Fawcett WJ, Jenkins JG. Efficacy of epidural blood patch in the obstetric population. Int J Obstet Anesth 1999; 8: 105-109.
MEDICO LEGAL QUERY? Dear Members, Of late, cases under CPA, against anaesthesiologists, are increasing throughout the country. Though most of the cases are dismissed ultimately by the court of law, they are causing lot of tension and worry for the anaesthesiologists and their families. The following members of ISA, are qualified in ‘Law’ and are well versed in medico-legal aspects.They have kindly volunteered to answer any of the medico legal queries related to our profession raised by any of the members of ISA. Please contact either of them, in case of necessity. Dr. D.N. Upasani Medical Director H.J. Doshi Ghatkopar Hindu Sabha Hospital, Ghatkopar (W), Mumbai–400 086, MAHARASHTRA Ph : (022) 23683553, Mobile: 9820377574 E-mail :
[email protected]
Dr. S.C. Parakh Past G.C. Member, ISA 4-II Daffodil Apartment Durgabhai Deshmuk Colony, Hyderabad – 500 007 (AP) E-mail:
[email protected]
