Spinal and Epidural Hematoma

The incidence of neurologic injury resulting from hematoma associated with neuraxial anesthesia is very low, with estimates of 1 in 150,000 and 1 in 220,000 for epidural and spinal anesthesia, respectively.^[230] A review of 61 cases of spinal hematoma associated with spinal or epidural anesthesia reported evidence of hemostatic abnormality in 68% of patients and difficult or bloody placement of needles and catheters in 25% of cases. Fifteen of the reported cases involved spinal anesthesia, with the remaining 46 receiving epidural anesthesia. ^[231]

A new risk factor for the development of spinal hematoma is a high-risk parturient who is receiving low-molecular-weight heparin (LMWH). Recent guidelines by the American Society of Regional Anesthesia suggest that neuraxial techniques should be deferred for 10 to 12 hours in a parturient who has received preoperative LMWH or 24 hours for parturients receiving higher doses of LMWH (e.g., enoxaparin, 1 mg/kg twice daily).^[232]