ACUTE SPINAL SUBDURAL-HEMATOMA AFTER ATTE MPTED SPINAL-ANESTHESIA

This is a report of a case of a subdural haematoma with resulting para plegia after attempted spinal anaesthesia. Epidural and subdural haema tomas are rare complications after central neural blockade. The compli cation described here was the result of an unsuccessful attempt to pun cture the spinal channel. The patient was a 72-year-old woman with a f racture of the left femoral neck, which it was intended to stabilize o peratively. Findings that made lumbar spinal puncture difficult were s evere overweight, and lordosis and scoliosis of the lumbar spine resul ting from degenerative changes. Spinal anaesthesia was suggested becau se the patient had eaten shortly before and because she suffered from asthma. From the aspect of haemostasis no contraindications were prese nt, and the anaesthesist was experienced in spinal anaesthesia even un der difficult anatomical conditions. Several unsuccessful attempts wer e made to puncture the lumbar spinal channel while the patient was lyi ng on her right side. It was also impossible to reach the spinal chann el from a median or left paramedian approach. We used atraumatic penci l-point needles (Sprotte gauge 24, 90 mm). No blood was aspirated duri ng any of the attempts. The surgical intervention was finally performe d under a general anaesthetic in view of the urgency. No significant c omplications occurred during the operation, and no neurological abnorm alities were observed immediately after or in the next 8 h after the o peration. At 12 h after the operation a paraparesis was found caudal t o L3. After this had been verified by radiological and neurological te sts, neurosurgical decompression was carried out as quickly as possibl e. During the operation a distinct subdural haematoma without any dete ctable source of bleeding was discovered. Even after surgical revision and evacuation of the remaining haematoma it was not possible to reve rse the paraplegia, in spite of rehabilitation measures. Despite a cer tain fragility of the vessel and pretreatment with pentoxifylline and thromboembolic prophylaxis with low-molecular heparin starting postope ratively, it must be assumed that a vessel accompanying one of the spi nal nerves was punctured, possibly, the radiculomedullary vessel of Ad amkiewicz. A similar case was published in 1988 by Parker. In the pres ent case it must be assumed that the vessel was punctured during a par amedian approach in the area of the foramen intervertebrale, as the sp inal channel was definitely not entered. Although this is an extremely rare complication, we conclude that close neurological controls are e ssential at least during the first 24 h after surgery, even after an u nsuccessful attempt at central neural blockade.