KEY WORDS: Lumbar. Epidural hematoma. Surgery.
Hematoma lumbar epidural postpunción lumbar; in-
PALABRAS CLAVE: Lumbar. Hematoma epidural. Ciru-
gía. HBPS. Mielografía.
Multilevel lumbar procedures, anatomic abnormalities,
traumatic puncture with multiple attempts, and coagulation
disorders or anticoagulation therapy are significant risk fac-
tors for spinal epidural hematoma development
as most of them are clinically insignificant, but may cause
severe and rapid neurological deterioration.
We report a case of a woman developing epidural
hematoma with neurological deterioration three days after
Lumbar epidural hematoma following lumbar puncture: the role of high dose
LMWH and late surgery. A case report
D. Gurkanlar; C. Acikbas; G.K. Cengiz and R. Tuncer
Department of Neurosurgery. Akdeniz University. School of Medicine. Antalya. Türkiye.
Abbreviations. CMT: computerized myelo-tomography. CT: com-
puterized tomography. HBPM: heparina de bajo peso molecular.
HEE: hematoma epidural espinal. LMWH: low molecular weight
heparin. MRI: resonancia magnética. SEH: spinal epidural
A 51-year-old woman suffering from right leg pain
was admitted to our hospital. Her neurologic examination
revealed only the right positive straight leg raising test, at
45°. The patient had had atrial and mitral valve replacement
operations in 1988 and 1998. Therefore we could not per-
form magnetic resonance imaging (MRI). We could only
performed lumbar myelography and computerized myelo-
graphy (CTM) three weeks after stopping her coumadine
treatment. The patient received low molecular weight
heparin (LMWH) (60/day) during this period and her
coagulation variables were in normal limits. Lumbar mye-
logram which was performed at L3-4 level, demonstrated
abrupt termination of the right L5 root (Figure 1) and CTM
showed the posterolateral disc herniation which prevented
filling of the nerve root (Figure 2). After this examination,
conservative therapy was started due to the absence of sig-
nificant neurologic deficit and the patient was discharged.
After the lumbar puncture, the patient began to suffer from
persistent low back pain, progressive right leg weakness
and numbness. Although her motor weakness began imme-
diately after the lumbar puncture, it was apparent on the
third day of the course. She was admitted to our outpatient
clinic again on the sixth day of lumbar puncture and her
neurological examination revealed 2/5 motor strength of
right lower extremity, hypoesthesia below L1 level and
loss of Achilles and patellar reflexes. The CT study of the
lumbar region revealed a right dorsolateral isodense mass
Lumbar epidural hematoma following lumbar puncture: the role of HIGH dose lmwh and late surgery. A case report
Figure 1. Lumbar myelogram demonstrating abrupt termi-
Figure 2. CTM showing the posterolateral disc herniation
Figure 3. CT of the lumbar region revealed a right
3) and a right sided L2 hemiparcial laminectomy performed
immediately. A soft red-bluish mass, without fluid parts,
measuring nearly 4 cm, extending from right dorsolateral
to the left dorsolateral side of the tecal sac, with a capsule
was reached following flavectomy and decompression,
by evacuation of the hematoma, was performed. After
the hematoma removal we recognized that the lumbar
puncture had been performed at the L2-3 space. The final
pathological diagnosis of the operation material was orga-
nized hematoma. Postoperative CT revealed no hematoma
at operation site. Immediately after the operation the back
pain resolved. The strength of the right lower extremity
was 3/5 proximally and 2/5 distally, at discharge.
Spinal epidural hematoma (SEH) is a known complica-
tion of spinal surgery1
, but the incidence of postope-
rative SEHs that result in neurologic deficits is extremely
rare. Lawton et al
reported the incidence rate to be 0.1%.
the patient who either demonstrates a new postoperative
neurologic deficit or develops deficits in the immediate
postoperative period that are consistent with cauda equina
. SEH will cause spinal pain and root pain,
features will be dependent on the level of compression
SEH is a significant cause of morbidity and needs to
decompression and evacuation of the hematoma is criti-
and/or have a preoperative coagulopathy are at a signifi-
cantly higher risk of developing an epidural hematoma
attempts, and coagulation disorders or anticoagulation
therapy are also risk factors for spinal epidural hematoma
. Spontaneous epidural hematomas have been
They have also been associated with thrombolytic therapy
Anticoagulation therapy especially with LMWH and
coagulation disorders are the main risk factors in the
formation of spinal epidural hematoma following lumbar
. The introduction of higher dose of LMWH
the reported incidence of neuroaxial hematomas compared
with what was reported in Europe (30 mg/day)
attempt and the coagulation variables were in normal
ranges, an epidural hematoma and related symptoms occu-
rred in our patient probably due to a coagulopathy.
Vandermeulen et al
found that most patients with an
made good or partial recovery of neurologic function. We
operated our patients on the sixth day of complaints howe-
ver it is too late for surgery according to Vandermeulen
of pain and her neurologic examination revealed marked
improvement of the neurologic deficits.
The insertion site (thoracic vs. lumbar) and the midline
or paramedian approach of the epidural space are some-
times believed to increase the risk of epidural bleeding.
There is no evidence that the risk for hematoma formation
is lower with a midline compared with paramedian appro-
attempts and have o lower success rate compared with the
and arterial bleeding can also cause spinal
. Some authors also believe that
an epidural vein either by a sudden increase in the intra-
abdominal pressure impacting on a previously damaged or
weakened vein, or by mild trauma
In our case the lumbar puncture was performed at L2-3
not have found any exact data about lumbar puncture which
if it is performed at higher lumbar levels increases epidural
Current administration of high doses of LMWH can
cause SEH even after a lumbar puncture, which was per-
formed without multiple attempts.
Although surgery performed within 8 hours made good
or partial recovery of neurologic function, laminectomy
and epidural hematoma evacuation performed after three
days can also have successful results.
1. Cohen, J.E., Ginsberg, H.J., Emery, D., et al.: Fatal spon-
taneous spinal epidural hematoma following thrombolysis for
myocardial infarction. Surg Neurol 1998; 49: 520-522.
2. Coope,r D.W.: Spontaneous spinal epidural hematoma.
J Neurosurg 1967; 26: 343-345.
3. Delamarter, R.B., Sherman, J., Carr, J.B.: Pathophy-
siology of spinal cord injury: recovery after immediate and
delayed decompression. J Bone Joint Surg Am 1995; 77:
4. Groen, R.J.M., Ponssen, H.: The spontaneous spinal
epidural hematoma. A study of aetiology. J Neurol Sci 1990;
Gurkanlar and cols
neuroaxial anesthesia. Thrombosis Res 2001; 101: 141-154.
6. Horlocker, T.T., Wedel, D.J.: Neuroaxial blockade and
low molecular weight heparin. Balancing preoperative analge-
sia and thromboprophylaxis. Reg Anesth 1998; 23: 164-177.
7. Horlocker, T.T., Wedel, D.J., Schroeder, D.R., Rose,
S.H., Elliot, B.A., McGregor, D.G., et al.: Preoperative anti-
platelet therapy does not increase the risk of spinal hematoma
associated with regional anesthesia. Anesth Analg 1995; 80:
8. Houten, K.J., Ericco, T.J.: Paraplegia after lumbosacral
nerve root block: report of three cases. The Spine Journal
2002; 2: 70-75.
9. Johnston, R.A.: The management of acute spinal cord
compression. J Neurol Neurosurg Psychiatry 1993; 56: 1046-
anesthesia ‘learning curve’: what is the minimum number of
epidural and spinal blocks to reach consistency? Reg Anesth
1996; 21: 182-190.
11. Kou, J., Fischgrund, J., Biddinger, A., Herkowitz, H.:
Risk factors for spinal epidural hematoma after spinal surgery.
Spine 2002; 27: 1670-1673.
12. Krolick, M.A., Cintron, G.B.: Spinal epidural hema-
toma causing cord compression after tissue plasminogen acti-
vator and heparin therapy. South Med J 1991; 84: 670-671.
13. Laglia, A.G., Eisenberg, R.L., Weinstein, P.R., et al.:
Spinal epidural hematoma after lumbar puncture in liver
disease. Ann Intern Med 1978; 88: 515-516.
14. Lawton, M.T., Porter, R.W., Heiserman, J.E., et al.:
Surgical management of spinal epidural hematoma: relatio-
nship between surgical timing and neurological outcome. J
Neurosurg 1995; 83: 1-7.
15. Lunardi, P., Mastronardi, L., Lo Bianco, F., Schettini,
G., Puzzilli, F.: Chronic spontaneous spinal epidural haema-
toma simulating a lumbar stenosis. Eur Spine J 1995; 4: 64-
16. Mayfield, F.H.: Complications of laminectomy. Clin
17.Mohazab, H.R., Langer, B., Spigos, D.: Spinal epidural
hematoma in a patient with lupus coagulopathy: MR findings.
AJR 1993; 160: 853-854.
18. Pear, B.L.: Spinal epidural hematoma. AJR 1972; 115:
19. Persson, J., Flisberg, P., Lundberg, J.: Thoracic
epidural anesthesia and epidural hematoma. Acta Anesthesiol
Scand 2002; 46: 1171-1174.
20. Schwartz, F.T., Sartavi, M.A., Fox, J.L.: Unusual
hematomas outside the spinal cord. J Neurosurg 1973; 39:
21. Sweasey, T.A., Coester, H.C., Rawal, H., Blaivas, M.,
Mcgillicuddy, J.E.: Ligamentum flavum hematoma. Report of
two cases. J Neurosurg 1992; 76: 534-537.
22. Tanaka, K., Watanabe, R., Harada, T., Dan, K.: Exten-
sive application of epidural anesthesia and analgesia in a
University hospital: Incidence of complications related to
technique. Reg Anesth 1993; 18: 34-38.
23. Vandermeulen, E.P., Aken, H.V., Vermylen, J.: Anti-
coagulants and spinal-epidural anesthesia. Anesth Analg 1994;
Gurkanlar, D.; Acikbas, C.; Cengiz, G.K.; Tuncer, R.:
Lumbar epidural hematoma following lumbar puncture:
the role of HIGH dose lmwh and late surgery. A case report.
Neurocirugía 2007; 18: 52-55.
Mahallesi. Portakal Çiçeği Antalya. Türkiye.