The patient was a 30-year-old primipara with a twin pregnancy at 36 weeks. She had an accompanying premature rupture of the membrane and had planned to have a cesarean section. She did not have a past medical history and her height and weight was 164 cm and 69 kg, respectively. The physical examination, blood test, urine analysis, chest x-ray, and EKG were all within normal limits (). Combined spinal-epidural anesthesia was planned because the patient wanted regional anesthesia for the twin pregnancy and there were with no special contraindications.
Preanesthesia medication was not used. EKG monitoring, non-invasive automatic blood pressure measuring, and pulse oximetry were set up after the patient arrived at the surgical theatre. The patient's blood pressure was 130/80 mmHg; heart rate was 90 beats per minute before induction. 3 L of oxygen was provided through nasal prong while observing the patient's vital signs. She was positioned left lateral decubitus for the regional anesthesia using an 18 G modified Tuohy (Espocan®, B. Brown, Germany) needle, and epidural access between the third and fourth lumbar vertebrae was attempted. Right after the puncture, bleeding was observed through the needle, and the puncture needle was immediately removed. Compression was attempted for bleeding control. Since there was no observed bleeding or hematoma in the puncture area, a second attempt at puncture was tried between the second and third lumbar vertebrae with a 27 G subarachnoid needle inserted in an 18 G epidural needle after examining the epidural area with the loss of resistance technique. After observing spontaneous flow of CSF fluid, 5 mg of 0.5% bupivacaine dextrose was injected, and then, the subarachnoid needle was removed. The subarachnoid needle bevel was toward the cephalic, with a 20 G epidural catheter (Perifix® soft tip, Braun, Germany) located 3 cm from the cephalic. Then, the patient was repositioned to the supine position. There were no difficulties during the procedure, and she did not complain of any dysesthesia, numbness, or pain. After no blood or CSF had been aspirated, a 3 ml test amount of epinephrine (1 : 200,000) was injected through the epidural catheter with a 3-minute observation period. The patient was stable with blood pressure at 130/80 mmHg and heart rate at 95 beats per minute. 10 minutes after intraspinal injection, the level of the sensory block was at the tenth thoracic spinal nerve segment. In order to increase the level of the sensory block, after checking again that no blood had been aspirated, 5 ml of 2% lidocaine mixed with epinephrine (1 : 200,000) was injected repeatedly with a total of 20 ml being injected. After 20 minutes, the level of the sensory block did not change remaining at the tenth thoracic spinal nerve segment. Therefore, it became necessary to switch to general anesthesia. 250 mg of Thiopental and 75 mg of succinylcholine were infused. After observed loss of consciousness and muscle relaxation, intubation was done. While the surgery was proceeding, the anesthesia was maintained using 2 L/min of O2, 2 L/min of N2O, 5 vol% of desflurane, and 4 mg of vecuronium until the babies were delivered. 4 minutes after induction, the baby boy was delivered through cesarean section, and the baby girl was delivered 1 minute after the birth of the boy. The babies weighed 2.4 kg and 2.6 kg with 5-minute-apgar scores of 7 and 8. After the placenta was expelled, 20 units of oxytocin mixed with 100 ml of normal saline were infused, but uterine contraction did not successfully proceed. Bleeding of more than 3,000 ml occurred in the 5 minutes after delivery. 0.2 mg of methylergonovine was injected to advance uterine contraction, but the bleeding continued. Her hemoglobin level dropped to 8.4 mg/dl. Since massive bleeding was not expected before operation, there was no blood prepared. One hour after the operation, 2 units of packed RBCs prepared under emergency conditions were transfused. Crystalloid solution and colloid solution was infused before the transfusion with repeated injections of ephedrine to maintain systolic blood pressure above 90 mmHg. After the operation, blood pressure was maintained above 90/40 mmHg without an inotropic or vasopressor agent. Total anesthetic time was 2 hours 10 minutes; the operation time was 1 hour 20 minutes. Total bleeding during anesthesia was approximately 4,000 ml; urine amount was approximately 200 ml, and 2 units of packed RBCs were transfused. 1,000 ml crystalloid and 2,000 ml colloid solutions were infused. In the recovery room, the patient received an extra 2 units of packed RBCs and 2 units of fresh frozen plasma were transfused.
After arriving at the recovery room, the level of the sensory block was below T12. She was transferred to the ward after 1 hour after partial recovery of sensory and motor function was observed and the epidural catheter was removed. Right after arriving at the ward, a blood test was done; hemoglobin was 10.1 mg/dl with prolonged PT and aPTT each measured at 21.1 sec and 52.3 sec, respectively. Vaginal bleeding continued after arriving at the ward. Intrauterine compression was attempted by foley catheter insertion and 2 units of fresh frozen plasma were transfused. 4 hours after the operation, PT and aPTT were 19.3 sec and 46.4 sec. Hemoglobin level decreased to 7.1 mg/dl and platelet count decreased to 82,000/mm3. 3 units of packed RBCs and 10 units of platelet concentrate were transfused. The vaginal bleeding continued but decreased.
At the ward, the patient complained of abdominal pain and back pain but was able to get some sleep by controlling pain through patient-controlled-analgesia (PCA). Next morning, 10 hours after the operation, the back pain continued, and sensory and motor paralysis on both lower extremities were observed. Emergency magnetic resonance imaging (MRI) was done and a compressive mass was found at the posterior of the lumbar vertebrae (). Acute epidural hematoma was diagnosis, and an infusion of high dose steroid therapy was carried out. The patient was transferred to the surgical theatre 4 hours after symptoms developed. An emergency decompression laminectomy was done to get rid of the epidural hematoma at the L2/L3 segment of the lumbar vertebrae. The patient's coagulation process did not work well and more than 1,000 ml of bleeding occurred with 3 units of packed RBCs being transfused. After the operation, motor and sensory function of the lower extremities did not change but the pain in the back had mildly improved. However, 1 day after the hematoma was removed, the back pain had become aggravated. Another emergency MRI was done and the hematoma was found to have occurred again, and the operation was done again. She complained of excessive numbness in her lower extremities but muscle strength gradually recovered. One month after the operation, she was discharged after she was able to walk without any working aid with some restrictions. Five months after the operation, neurological symptoms were totally improved without any sequelae.
Initial T2 weighted image demonstrate a high signal intense epidural hematoma with fluid-fluid level that extends from L2 to L3 and is posterior to the spinal cord, producting severe compression of distal spinal cord and proximal thecal sac.