case report delayed postoperative epidural hematoma...

Hindawi Publishing CorporationCase Reports in OrthopedicsVolume 2013 Article ID 861961 4 pageshttpdxdoiorg1011552013861961

Case ReportDelayed Postoperative Epidural Hematoma PresentingOnly with Vesicorectal Disturbance

Hiroto Kamoda12 Tetsuhiro Ishikawa1 Masayuki Miyagi1

Yawara Eguchi1 Sumihisa Orita1 Miyako Suzuki1 Yoshihiro Sakuma1 Yasuhiro Oikawa1

Kazuyo Yamauchi1 Gen Inoue3 Kazuhisa Takahashi1 and Seiji Ohtori1

1 Department of Orthopaedic Surgery Graduate School of Medicine Chiba University 1-8-1 Inohana Chuo-ku Chiba 260-8677 Japan2Department of Orthopaedic Surgery Chiba Cancer Center 666-2 Nitona Chuo-ku Chiba 260-8717 Japan3Department of Orthopaedic Surgery Kitasato University School of Medicine 1-15-1 Kitasato Minami-ku SagamiharaKanagawa 252-0374 Japan

Correspondence should be addressed to Hiroto Kamoda kamodahirotogmailcom

Received 1 July 2013 Accepted 31 July 2013

Academic Editors V Chouhan M Gotoh H Hatano and C D Moussallem

Copyright copy 2013 Hiroto Kamoda et alThis is an open access article distributed under the Creative CommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom wasvesicorectal disturbance A 68-year-oldmanwith degenerative spinal stenosis underwent lumbar decompression and instrumentedposterolateral spine fusion The day after his discharge following an unremarkable postoperative course he presented to theemergency room complaining of difficulty in urination An MRI revealed an epidural fluid collection causing compression of thethecal sacThefluidwas evacuated revealing a postoperative hematoma After removal of the hematoma his symptoms disappearedimmediately and his urinary function completely recovered Most reports have characterized postoperative epidural hematoma asoccurring early after operation and accompanied with neurological deficits But it can happen even two weeks after spinal surgerywith no pain Surgeons thus may need to follow up patients for at least a few weeks because some complications such as epiduralhematomas could take that long to manifest themselves

1 Introduction

Symptomatic epidural hematoma is a well-known butuncommon postoperative complication of spinal surgery thatusually presents with severe back and leg painThe incidencerate is estimated to be around 01 [1 2]Most published casesof symptomatic epidural hematoma state that it developswithin a few hours after operation Cabana et al for instancereported an average delay of 53 hours from the lumbarintervention to the subsequent onset of hematoma symptoms[3]

Even rarer still are cases of delayed symptomatic epiduralhematoma Uribe et al [4] who defined ldquodelayedrdquo as anoccurrence more than three days after operation reportedseven cases in his study Sokolowski et al reported fourcases of delayed symptomatic epidural hematoma withoutcoagulopathy [5] In these cases though the initial symptoms

included severe pain and muscle weakness at the level ofprevious surgery the same symptom pattern that accompa-nies hematomas occurring shortly after surgery

Wenow report a case of postoperative epidural hematomadeveloping two weeks after surgery whose only presentingsymptom was vesicorectal disturbance

2 Case Report

A 68-year-old man with a medical history of hypertensionwas referred to our hospital with progressively increasinglower back and left leg pain despite analgesic treatmentPreoperative imaging revealed degenerative spinal stenosisfrom L2 to L5 with spondylolisthesis at L3 to L4 and L4 to L5(Figure 1) Preoperative neurological examination detectedno motor or sensory deficits The patient did not report anybowel or bladder function loss at that time He also had no

2 Case Reports in Orthopedics

Figure 1 Preoperative imaging Sagittal reconstruction of a post-myelography computed tomography (CT) scan demonstrates L2-5 multiple spinal stenosis and concurrent grade I degenerativespondylolisthesis at L34 and L45

history of prior anticoagulation therapy and preoperativecoagulation studies were normal

The patient underwent L2 to L5 decompressive laminec-tomies and L3 to L5 instrumented posterolateral spinal fusionwith autograft bone No dural tears occurred intraoperativelyAfter achievement of excellent hemostasis a surgical drainwas placed at the time of closure Intraoperative blood losswas approximately 500mL

On postoperative day 2 the drain was removed andprogressive physical therapy was started His postoperativecourse was unremarkable His symptoms resolved and hewas discharged on day 14 That same evening he felt asensation of lower abdominal bloating

The next morning (postoperative day 15) he presented tothe emergency room complaining of difficulty in urinatingHis bladder was found to contain approximately 500mLof urine He did not report any leg or back pain Physicalexamination revealed nomotor or sensory deficits Emergentlumbar magnetic resonance imaging (MRI) visualized a T2high weighed epidural mass at the surgical site flatteningthe thecal sac from L4 to L5 (Figure 2) We immediatelyperformed surgical evacuation manually with irrigation andin the process discovered a large consolidated hematoma(45 cm times 2 cm) which we removed (Figure 3) No obvioussource of bleeding could be identified We placed an epiduraldrain in the surgical site before closure which we kept therefor 5 days Postoperative MRI showed complete resolutionof the epidural hematoma (Figure 4) After evacuationhis symptoms immediately disappeared and his urinaryfunction recovered completelyWe allowed him to walk againafter the removal of drain and he was discharged home onday 10

3 Discussion

Several published studies have discussed the etiology ofpostoperative epidural hematoma Kou et al [2] identified

multilevel procedures and the presence of preoperative coag-ulopathy as possible significant risk factors Awad et al [6]divided potential risk factors into two categories preop-erative and intraoperative factors Significant preoperativerisk factors included nonsteroidal anti-inflammatory use andpatient age more than 60 years significant intraoperativerisk factors included multiple-level operation anemia andlarge blood loss Sokolowski et al [7] reported that agegreater than 60 years multilevel procedures and preoper-ative international normalized ratio (INR) correlated withpostoperative hematoma volumes Even though our patientindeed had several recognized risk factorsmdashage more than60 years use of analgesic agents and multilevel surgerymdashhe had no neurological symptoms during his hospitalizationThis would imply the nonexistence of an epidural hematomaduring the early postoperative period

Regarding delayed postoperative epidural hematomaParthibian and Majeed described one such case which devel-oped following an episode of violent twisting movement[8] Since our patient had no symptoms at his time ofdischarge on postoperative day 14 but then had developedenuresis by the next morning without any episode of violentmovement we would suspect that a general increase inactivity after discharge triggered epidural bleeding and agrowing hematoma

The other unusual aspect of our case is that our patientonly complained of difficulty urinating and did not reportpain or muscle weakness at the time of onset Symptomatichematoma usually starts with a stabbing pain at the operativesite followed by paresthesia radicular pain and neurologicpalsy [9] In our case the MRI showed the hematoma atthe L4-5 level pressing the thecal sac from the posteriorside While our literature search discovered several reportsof postoperative epidural hematoma causing cauda equinasyndrome [10ndash14] we did not find any reports of hematomacausing only vesicorectal disturbance without severe pain ormuscular weakness Because urinary function innervation isfrom S2 to S4 dysuria theoretically could occur if only thecentral part of thecal sac was being compressed at the L4-5level However since central compression was not the type ofthecal sac compression in our patient the reason for present-ing only with vesicorectal disturbance remains unknown andfurther study is thought to be needed on this point

Although most surgeons will leave in drains at thesurgical site in an effort to prevent the formation of ahematoma following lumbar spine surgery controversy per-sists as to whether indwelling drains are effective in prevent-ing hematomas especially as several studies have claimedthat surgical drains are not always necessary for lumbar spinesurgery Brown and Brookfield [15] for instance performed arandomized study comparing lumbar spine surgery patientswho had a drain placed before closure with those who didnot and they found that no patient in either group developeda hematoma Similarly Kanayama et al [16] reported that useof a drain had no influence on the risk of hematoma in singlelevel lumbar decompression In our case a symptomatichematoma formed despite our placing a surgical drainindicating that surgical drains may not be sufficient forpreventing hematoma-related complications

Case Reports in Orthopedics 3

(a) (b)

Figure 2 (a) Magnetic resonance imaging (MRI) T2-weighed sagittal image acquired 15 days postoperatively demonstrates a convex-shapedlesion at the surgical site (998771) compressing the thecal sac (b) MRI T2-weighed axial image shows a posterior high intensity area completelyflattening the thecal sac from both posterior right and posterior left sides

1 cm

Figure 3 A large consolidated hematoma (45 cm times 2 cm) wasremoved

Figure 4 MRI T2-weighed sagittal image after hematoma evacua-tion shows no compression of the thecal sac

Patients with symptomatic hematomas are often treatedwith surgical evacuation immediately to prevent neurologicalsequelae Lawton et al [1] recommended immediate surgical

evacuation of the hematoma based on their study findingsthat patients taken to surgery within 12 hours had betterneurological outcomes In our case being able to performsurgical evacuation approximately five hours after our patientpresented to the emergency room may have been a majorfactor in his recovering completely

In conclusion delayed postoperative epidural hematomais a rather rare complication of spinal surgery When thiscomplication arises it usually presents with severe leg or backpain but not always as our patient demonstrated This caseillustrates the need for surgeons to follow up patients for atleast a few weeks after lumbar spine surgery because somecomplications such as epidural hematomas could take thatlong to manifest themselves

Conflict of Interests

The authors declare that they have no conflict of interests

References

[1] M T Lawton R W Porter J E Heiserman R Jacobowitz VK H Sonntag and C A Dickman ldquoSurgical management ofspinal epidural hematoma relationship between surgical timingand neurological outcomerdquo Journal of Neurosurgery vol 83 no1 pp 1ndash7 1995

[2] J Kou J Fischgrund A Biddinger and H Herkowitz ldquoRiskfactors for spinal epidural hematoma after spinal surgeryrdquo Spinevol 27 no 15 pp 1670ndash1673 2002

[3] F Cabana V Pointillart J-M Vital and J Senegas ldquoPostop-erative compressive spinal epidural hematomas 15 cases anda review of the literaturerdquo Revue de Chirurgie Orthopedique etReparatrice de lrsquoAppareil Moteur vol 86 no 4 pp 335ndash3452000


[4] J Uribe K Moza O Jimenez B Green and A D O LevildquoDelayed postoperative spinal epidural hematomasrdquo Spine Jour-nal vol 3 no 2 pp 125ndash129 2003

[5] M J Sokolowski M Dolan A Aminian M H Haak and MF Schafer ldquoDelayed epidural hematoma after spinal surgery areport of 4 casesrdquo Journal of Spinal Disorders and Techniquesvol 19 no 8 pp 603ndash606 2006

[6] J N Awad K M Kebaish J Donigan D B Cohen and J PKostuik ldquoAnalysis of the risk factors for the development ofpost-operative spinal epidural haematomardquo Journal of Bone andJoint Surgery B vol 87 no 9 pp 1248ndash1252 2005

[7] M J Sokolowski T A Garvey J Perl et al ldquoProspective studyof postoperative lumbar epidural hematoma incidence and riskfactorsrdquo Spine vol 33 no 1 pp 108ndash113 2008

[8] C J Parthiban and S A Majeed ldquoDelayed spinal extraduralhematoma following thoracic spine surgery and resulting inparaplegia a case reportrdquo Journal of Medical Case Reports vol2 article 141 2008

[9] D Scavarda P Peruzzi A Bazin et al ldquoPost-operative spinalepidural hematoma 14 casesrdquo Neurochirurgie vol 43 no 4 pp220ndash227 1997

[10] T Henriques C Olerud M Petren-Mallmin and T AhlldquoCauda equina syndrome as a postoperative complication in fivepatients operated for lumbar disc herniationrdquo Spine vol 26 no3 pp 293ndash297 2001

[11] K M Kebaish and J N Awad ldquoSpinal epidural hematomacausing acute cauda equina syndromerdquoNeurosurg Focus vol 16no 6 p e1 2004

[12] T Kaner M Sasani T Oktenoglu B Cirak and A F OzerldquoPostoperative spinal epidural hematoma resulting in caudaequina syndrome a case report and review of the literaturerdquoCases Journal vol 2 no 7 article 8584 2009

[13] S Podnar ldquoCauda equina lesions as a complication of spinalsurgeryrdquoEuropean Spine Journal vol 19 no 3 pp 451ndash457 2010

[14] C D Moussallem C A El-Yahchouchi A C Charbel and GNohra ldquoLate spinal subdural haematoma after spinal anaesthe-sia for total hip replacementrdquo Journal of Bone and Joint SurgeryB vol 91 no 11 pp 1531ndash1532 2009

[15] M D Brown and K F W Brookfield ldquoA randomized studyof closed wound suction drainage for extensive lumbar spinesurgeryrdquo Spine vol 29 no 10 pp 1066ndash1068 2004

[16] M Kanayama F Oha D Togawa K Shigenobu and THashimoto ldquoIs closed-suction drainage necessary for single-level lumbar decompression Review of 560 casesrdquo ClinicalOrthopaedics and Related Research vol 468 no 10 pp 2690ndash2694 2010

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


Figure 1 Preoperative imaging Sagittal reconstruction of a post-myelography computed tomography (CT) scan demonstrates L2-5 multiple spinal stenosis and concurrent grade I degenerativespondylolisthesis at L34 and L45

history of prior anticoagulation therapy and preoperativecoagulation studies were normal

The patient underwent L2 to L5 decompressive laminec-tomies and L3 to L5 instrumented posterolateral spinal fusionwith autograft bone No dural tears occurred intraoperativelyAfter achievement of excellent hemostasis a surgical drainwas placed at the time of closure Intraoperative blood losswas approximately 500mL

On postoperative day 2 the drain was removed andprogressive physical therapy was started His postoperativecourse was unremarkable His symptoms resolved and hewas discharged on day 14 That same evening he felt asensation of lower abdominal bloating

The next morning (postoperative day 15) he presented tothe emergency room complaining of difficulty in urinatingHis bladder was found to contain approximately 500mLof urine He did not report any leg or back pain Physicalexamination revealed nomotor or sensory deficits Emergentlumbar magnetic resonance imaging (MRI) visualized a T2high weighed epidural mass at the surgical site flatteningthe thecal sac from L4 to L5 (Figure 2) We immediatelyperformed surgical evacuation manually with irrigation andin the process discovered a large consolidated hematoma(45 cm times 2 cm) which we removed (Figure 3) No obvioussource of bleeding could be identified We placed an epiduraldrain in the surgical site before closure which we kept therefor 5 days Postoperative MRI showed complete resolutionof the epidural hematoma (Figure 4) After evacuationhis symptoms immediately disappeared and his urinaryfunction recovered completelyWe allowed him to walk againafter the removal of drain and he was discharged home onday 10

3 Discussion

Several published studies have discussed the etiology ofpostoperative epidural hematoma Kou et al [2] identified

multilevel procedures and the presence of preoperative coag-ulopathy as possible significant risk factors Awad et al [6]divided potential risk factors into two categories preop-erative and intraoperative factors Significant preoperativerisk factors included nonsteroidal anti-inflammatory use andpatient age more than 60 years significant intraoperativerisk factors included multiple-level operation anemia andlarge blood loss Sokolowski et al [7] reported that agegreater than 60 years multilevel procedures and preoper-ative international normalized ratio (INR) correlated withpostoperative hematoma volumes Even though our patientindeed had several recognized risk factorsmdashage more than60 years use of analgesic agents and multilevel surgerymdashhe had no neurological symptoms during his hospitalizationThis would imply the nonexistence of an epidural hematomaduring the early postoperative period

Regarding delayed postoperative epidural hematomaParthibian and Majeed described one such case which devel-oped following an episode of violent twisting movement[8] Since our patient had no symptoms at his time ofdischarge on postoperative day 14 but then had developedenuresis by the next morning without any episode of violentmovement we would suspect that a general increase inactivity after discharge triggered epidural bleeding and agrowing hematoma

The other unusual aspect of our case is that our patientonly complained of difficulty urinating and did not reportpain or muscle weakness at the time of onset Symptomatichematoma usually starts with a stabbing pain at the operativesite followed by paresthesia radicular pain and neurologicpalsy [9] In our case the MRI showed the hematoma atthe L4-5 level pressing the thecal sac from the posteriorside While our literature search discovered several reportsof postoperative epidural hematoma causing cauda equinasyndrome [10ndash14] we did not find any reports of hematomacausing only vesicorectal disturbance without severe pain ormuscular weakness Because urinary function innervation isfrom S2 to S4 dysuria theoretically could occur if only thecentral part of thecal sac was being compressed at the L4-5level However since central compression was not the type ofthecal sac compression in our patient the reason for present-ing only with vesicorectal disturbance remains unknown andfurther study is thought to be needed on this point

Although most surgeons will leave in drains at thesurgical site in an effort to prevent the formation of ahematoma following lumbar spine surgery controversy per-sists as to whether indwelling drains are effective in prevent-ing hematomas especially as several studies have claimedthat surgical drains are not always necessary for lumbar spinesurgery Brown and Brookfield [15] for instance performed arandomized study comparing lumbar spine surgery patientswho had a drain placed before closure with those who didnot and they found that no patient in either group developeda hematoma Similarly Kanayama et al [16] reported that useof a drain had no influence on the risk of hematoma in singlelevel lumbar decompression In our case a symptomatichematoma formed despite our placing a surgical drainindicating that surgical drains may not be sufficient forpreventing hematoma-related complications


(a) (b)


1 cm








References























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)


1 cm








References























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















case report delayed postoperative epidural hematoma...

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