A 67-year-old man presented with chronic bilateral buttock and leg pain with ambulation, suggestive of neurogenic claudication. Plain radiographs showed lumbar disk degeneration at multiple levels with no evidence of instability. Magnetic resonance imaging (MRI) showed 4-level degenerative lumbar stenosis from L2 to the sacrum.
The patient's symptoms persisted despite 3 months of conservative measures including physical therapy and anti-inflammatory medications. He did experience temporal relief with selective bilateral injections of the L3 and L5 nerve roots. However, his severe claudication symptoms markedly affected his quality of life and decreased his ability to perform activities of daily living. Therefore, operative intervention was pursued, and preoperative planning was initiated.
The patient had a medical history significant for diabetes mellitus, coronary artery disease including a coronary artery bypass graft with a subsequent stenting procedure, and multiple myeloma, currently in remission. His medications included antihypertensive medications, oral and injectable hypoglycemic medications, and NSAIDs, but did not include anticoagulation medications. Given his complicated medical history, preoperative clearance was obtained by his primary care provider, in conjunction with his cardiologist, before proceeding to the operating room.
After medical clearance was obtained, he underwent routine, uncomplicated, 4-level lumbar decompression at the L2-L3, L3-L4, L4-L5, and L5-S1 levels. Blood loss was minimal (200 mL), and the wound was noted to be dry at the time of closure. A small surgical drain was placed before closure, and the patient was extubated and transferred to the surgical floor for postoperative management. The patient was noted to be doing well in the immediate postoperative period, with minimal drainage in the surgical drain.
Thirteen hours after completion of the operation, the patient began experiencing left-sided chest pain. The orthopedic house officer was called to evaluate the patient, and an electrocardiogram (ECG) and cardiac enzymes were obtained. ECG showed changes consistent with myocardial ischemia. Cardiology consultation was obtained, and full anticoagulation therapy was initiated because the patient was not a candidate for angiography as per the cardiology team. This included an initial intravenous heparin bolus based on the patient's weight, followed by a continuous intravenous heparin drip with a goal of a prothrombin time (PTT) of 60 to 80 seconds. The initial PTT was 123.5 seconds, which was corrected by stopping the heparin drip for 60 minutes and resuming the drip at a decreased rate. The subsequent PTT value was 65.6 seconds.
The patient's chest pain resolved, and he clinically progressed well, ambulating out of bed to a chair on postoperative day 1. At 24 hours postoperatively, the surgical drain had 50 mL of bloody drainage and was therefore discontinued. At 48 hours, the patient complained of severe sharp pain in the lower extremities followed by numbness and inability to move his legs. Physical examination revealed a profound motor deficit in his bilateral lower extremities, a sensory deficit below the T7 level, decreased rectal tone, and an absent bulbocavernosus reflex. Immediate decompression of the lumbar wound was carried out at the bedside by release of all sutures from the surgical site. Copious amount of blood was produced from the decompression; however, the patient's symptoms did not resolve.
The patient was immediately transported to radiology for emergency MRI of the entire spinal canal. MRI revealed an extensive spinal epidural hematoma extending from the inferior aspect of C4 to the surgical site in the lumbosacral levels (). Immediate reversal of all anticoagulation was performed with administration of fresh frozen plasma, platelets, and vitamin K, and the patient was taken to the operating room for prompt evacuation of the epidural hematoma. Surgical findings consisted of a large, consolidated, and continuous epidural hematoma. The consolidated nature of the hematoma precluded removal with a suction catheter and necessitated primary laminectomy at the cervical and thoracic levels and revision laminectomy at the lumbosacral levels. Evacuation was performed manually with irrigation, and 1 epidural drain and 2 paraspinal drains were placed before closure.
(A) MRI (T2) image of the cervical spine showing the epidural hematoma extending to the midcervical spine. (B) MRI (T2) image of the thoracolumbar spine showing the epidural hematoma extending to the prior surgical levels in the lumbar spine.
The patient was transported to the Intensive Care Unit postoperatively, where he was extubated without difficulty. After discussion with the cardiology team, anticoagulation was not used postoperatively because the patient's cardiac issues had resolved, and an inferior vena cava filter was placed for protection against future potential emboli. The remainder of his hospital stay was without complications, and he was discharged to the rehabilitation unit several days postoperatively.
Postoperatively, the patient showed signs of neurologic improvement. By 2 weeks, the patient had regained complete sensation and full motor strength in his legs. On discharge from the rehabilitation facility, he was ambulating with minimal assistance, but bowel and bladder function remained impaired. Postoperative MRI was obtained at 3 weeks after the operation. Images showed complete resolution of the epidural hematoma and no evidence of postlaminectomy instability (). Additional standing radiographs obtained at 3 months postoperatively did not show any evidence of postlaminectomy kyphosis (). At 8 months after the extensive decompression laminectomy, the patient noted minimal back pain, and bowel and bladder function continued to be impaired.
Postoperative MRI (T2) of the cervical spine showing evacuation of the epidural hematoma.
Figure 5 (A) Standing radiograph of the thoracic spine 2 months postoperatively showing no evidence of deformity after extensive laminectomy and decompression of the epidural hematoma. (B) Standing radiograph of the lumbar spine 2 months postoperatively showing (more ...)