THROMBOPROPHYLAXIS WITH LOW-DOSE HEPARIN (FRACTIONATED OR UNFRACTIONATED) - A CONTRAINDICATION TO SPINAL EPIDURAL ANESTHESIA/

Spinal or intracranial haematoma is a rare but severe complication of spinal/epidural anaesthesia with an incidence of less than 1:100 000. Co-agulation defects, traumatic puncture, and anticoagulant drugs are assumed to be risk factors for the development of this kind of haemato ma. Whether the risk of bleeding after spinal/epidural anaesthesia is increased by the administration of low-dose heparin (unfractionated or fractionated) for thromboprophylaxis is currently under discussion. M ethods and results. A randomised, prospective trial answering this que stion is not feasible because of the rarity of the complication. As an alternative, we identified all case reports described in the literatu re to date and analysed them for possible risk factors. In conjunction with spinal/epidural anaesthesia, we found 4 cases of spinal and 2 ca ses of intracranial haematoma following treatment with unfractionated heparin and 6 cases of spinal haematoma following treatment with diffe rent low-molecular-weight (LMW) heparins. In none of these cases could thromboprophylaxis with heparin be identified as the only risk factor for bleeding: in 11 of the 12 cases a difficult or traumatic puncture was described. Eleven patients showed three or more possible risk fac tors, e.g., coagulation defects, concomitant therapy with other antico agulant drugs, or anatomic abnormalities. Conclusion. We suggest that the development of spinal or intracranial haematoma after spinal/epidu ral anaesthesia is a multifactorial event. An influence of low-dose he parin prophylaxis as a cofactor cannot wholly be excluded because of t he difficulty of studying thp problem in a prospective way. The few ca se reports have to be seen in the context of millions of patients who have received either unfractionated or LMW heparin and lumbar or thora cic regional anaesthesia without any complication. We conclude that lo w-dose heparin prophylaxis (fractionated or unfractionated) is not a d efinite contraindication to spinal/epidural anaesthesia. High-risk (AS A III/IV) patients in particular benefit from effective postoperative analgesia achieved by local anaesthetics in combination with effective heparin thromboprophylaxis. Nevertheless, the absolute contraindicati ons for regional anaesthesia must be respected and an individual risk/ benefit analysis should be performed for every patient. An adequate ti me interval between application of heparin and regional anaesthesia or removal of a spinal/epidural catheter, atraumatic puncture technique, and careful neurologic monitoring during the post-operative period ca n minimise the risk of complications.