Abstract

Background: Spinal intradural hematomas rarely occur following spinal anesthesia. In this case, a 34-year-old postpartum female developed conus-cauda paraplegia (T12/L1–L5) due to an acute subdural hematoma after spinal anesthesia.

Case Description: Four-day postpartum, a 34-year-old female presented with severe paraplegia (1/5 motor power), complete T12–L1 sensory loss, and bowel incontinence. The lumbar magnetic resonance imaging (MRI) revealed a subacute subdural hematoma extending from the L1 to L5 levels. An urgent L1–L5 laminectomy was performed for clot evacuation. Within 3 postoperative months, she regained 4+/5 motor strength bilaterally and full bowel/bladder control.

Conclusion: Spinal anesthesia may cause acute/subacute subdural hematomas. Here, 4-day postpartum, a 34-year-old female became paraplegic due to a subacute T12-L5 subdural hematoma documented on an MRI scan. She underwent emergent decompression, and within 3 postoperative months, regained nearly normal function.

Keywords: Cauda equine, Intradural hematoma, Magnetic resonance imaging, Postpartum, Spinal anesthesia

INTRODUCTION

Spinal anesthesia may rarely result in a subacute subdural hematoma resulting in conus-cauda equina paralysis. Here, 4-day postpartum, a 34-year-old female suddenly became paraplegic due to a magnetic resonance (MR)-documented T12-L5 subacute subdural hematoma; she recovered nearly full function within 3 postoperative months.

CASE SUMMARY

A 34-year-old female underwent a lower segment cesarean section performed under spinal anesthesia, 4-day postpartum, she suddenly became paraplegic with 1/5 weakness in both lower extremities, a T12/L1 sensory level, and loss of bowel/bladder control. Laboratory investigations including a coagulation profile were within normal limits, and there was no evidence of a coagulopathy.

The contrast-enhanced lumbar MR imaging (MRI) revealed an early subacute subdural hematoma extending from L1 to L5. The hematoma appeared hyperintense on T1-weighted and hypointense on T2-weighted sequences; the hematoma caused significant compression of the conus medullaris and cauda equina [ Figures 1 and 2 ]. An emergent decompressive laminectomy was performed from L1 to L5 to evacuate the subdural hematoma. The patient tolerated the procedure well and was discharged 3 days later with improved bilateral lower limb motor strength (2/5). Notably, the Foley catheter was left in situ. Three months later, the patient’s motor strength improved to 4+/5 bilaterally, and she fully regained bowel and bladder function.

Figure 1:

Magnetic resonance imaging dorso-lumbar spine sagittal images (a) without contrast (T2-weighted image) and (b) with contrast (T1-weighted image) showing heterogenous signal intensity lesion/collection is seen in the spinal canal anteriorly causing compression over cauda equina nerve roots and conus tip as well (red arrow).

Figure 2:

Magnetic resonance imaging dorso-lumbar spine axial images. (a) (T2-weighted image) and (b) with contrast (T1-weighted image) – showing heterogenous signal intensity lesion/collection is seen in the spinal canal, intradural and anterior, causing compression over cauda equina nerve roots (red arrow).

DISCUSSION

Spinal intradural hematomas (SIHs) are rare but potentially catastrophic complication of neuraxial anesthesia. For this study, we identified fewer than 100 cases reported in the literature [ Table 1 ].[ 1 , 4 , 7 ] Our review of this particular case highlights how after spinal anesthesia performed in a postpartum female, early recognition and surgical removal of a T12-L5 subdural hematoma resulted in marked symptom resolution.

Table 1:

Summary of reported cases of spinal hematoma in the literature with varied etiologies, hematoma types, clinical presentations, management strategies, and outcomes.

Clinical symptoms of SIHs

Symptoms for patients with SIH usually appear within 3–5-day postepidural anesthesia. This is likely due to the gradual expansion of the hematoma.[ 9 ] Pain – often gluteal or radiating – is common and may be misinterpreted as being due to benign postpartum causes.[ 2 , 5 , 7 ] In our patient, the sudden, nocturnal worsening of pain unresponsive to analgesics prompted immediate further investigation.

MR studies diagnostic for SIH

MRI studies in general are the diagnostic “gold standard” or study of choice for diagnosing SIH. Typical MR characteristics of SIH include hyperintensity of the hematoma on T1-weighted and hypointensity on T2-weighted images. Our patient’s MR demonstrated an early subacute hematoma compressing the conus cauda equina from T12 to L5.

Bleeding risks for SIH

SIHs often occur in patients with coagulopathies or on anticoagulants.[ 3 , 4 , 8 ] However, our patient lacked such risk factors. Rather, she developed the SIH due to epidural needle insertion.

Surgical indications and timing for SIH

Emergent surgical decompression improves outcomes for patients presenting with acute paraplegia attributed to SIH. Our patient underwent emergent surgery and did well. Her outcome reinforces the overall need for early diagnosis based on clinical anticipation of an SIH, prompt MR imaging, and timely surgical intervention/decompression of the SIH to minimize the postoperative neurological sequelae.

CONCLUSION

Four-day postpartum, a 34-year-old female presented with complete motor/sensory paraplegia with loss of sphincter function attributed to a T12/L5 MR-documented acute subdural hematoma. She underwent an emergent surgical T12-L5 decompressive laminectomy, and within 3 postoperative months, nearly fully recovered.

Ethical approval:

Institutional review board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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