Akutes spinales Subduralhämatom nach Spinalanästhesieversuch

Zusammenfassung

Der hier vorgestellte Fall handelt von einem Subduralhämatom mit nachfolgender Paraplegie nach frustraner Spinalanästhesie. Das Besondere dieser Kasuistik ist, daß im Unterschied zu den zwar seltenen aber bekannten Komplikationen eines Epi- oder Subduralhämatoms nach rückenmarknahen Anästhesieverfahren diese Komplikation nicht als Folge einer definitiven Regionalanästhesie im Rückenmarkbereich, sondern nach einem mißglückten Versuch, den Spinalkanal zu punktieren, auftrat. Es handelt sich im hier geschilderten Fall um eine 72jährige Patientin mit Oberschenkelhalsfraktur links, die einer operativen Stabilisierung unterzogen werden sollte. Für die Spinalpunktion erschwerende Befunde waren: Adipositas permagna, Lordose und Skoliose der LWS infolge degenerativer Veränderungen. Als Ursache des Subduralhämatoms muß ursächlich das Punktionstrauma angenommen werden, da hämostaseologisch keine Blutungsneigung laborchemisch feststellbar war. Im Hinblick auf die Prognose einer zentralen Nervenwurzelschädigung im Rahmen eines punktionsbedingten Hämatoms sollte auch nach frustranen Spinalkanalpunktionsversuchen eine engmaschige, klinische neurologische Kontrolle in den ersten 24 h erfolgen.

Abstract

This is a report of a case of a subdural haematoma with resulting paraplegia after attempted spinal anaesthesia. Epidural and subdural haematomas are rare complications after central neural blockade. The complication described here was the result of an unsuccessful attempt to puncture the spinal channel. The patient was a 72-year-old woman with a fracture of the left femoral neck, which it was intended to stabilize operatively. Findings that made lumbar spinal puncture difficult were severe overweight, and lordosis and scoliosis of the lumbar spine resulting from degenerative changes. Spinal anaesthesia was suggested because the patient had eaten shortly before and because she suffered from asthma. From the aspect of haemostasis no contraindications were present, and the anaesthesist was experienced in spinal anaesthesia even under difficult anatomical conditions. Several unsuccessful attempts were made to puncture the lumbar spinal channel while the patient was lying on her right side. It was also impossible to reach the spinal channel from a median or left paramedian approach. We used atraumatic pencil-point needles (Sprotte gauge 24, 90 mm). No blood was aspirated during any of the attempts. The surgical intervention was finally performed under a general anaesthetic in view of the urgency. No significant complications occurred during the operation, and no neurological abnormalities were observed immediately after or in the next 8 h after the operation. At 12 h after the operation a paraparesis was found caudal to L3. After this had been verified by radiological and neurological tests, neurosurgical decompression was carried out as quickly as possible. During the operation a distinct subdural haematoma without any detectable source of bleeding was discovered. Even after surgical revision and evacuation of the remaining haematoma it was not possible to reverse the paraplegia, in spite of rehabilitation measures. Despite a certain fragility of the vessel and pretreatment with pentoxifylline and thromboembolic prophylaxis with low-molecular heparin starting postoperatively, it must be assumed that a vessel accompanying one of the spinal nerves was punctured, possibly, the radiculomedullary vessel of Adamkiewicz. A similar case was published in 1988 by Parker. In the present case it must be assumed that the vessel was punctured during a paramedian approach in the area of the foramen intervertebrale, as the spinal channel was definitely not entered. Although this is an extremely rare complication, we conclude that close neurological controls are essential at least during the first 24 h after surgery, even after an unsuccessful attempt at central neural blockade.