acta medica mediterranea, 2017, 33: 1163

SPINAL EPIDURAL HEMATOMA FOLLOWING CARDIO AORTIC SURGERY: ANY CORRELATIONPOSSIBLE?

VACCHIANO GIUSEPPE5, TECCHIA LIVIO BENEDETTO2, TORTORA FABIO3, PIERI MARIA4, BASILICATA PASCALE4, MASSONIFRANCESCO1, RICCI SERAFINO1

1Department of Anatomy, Histology, Legal Medicine and Orthopedics “Sapienza” University, Rome (Italy) - 2Department of Cardiology,Cardio-Surgery and Cardiovascular Emergency, University of Naples “Federico II” Naples (Italy) - 3Department of Medico Surgical cli-nical and Experimental Internal Medicine, University of Campania “Luigi Vanvitelli” Naples (Italy) - 4Department of AdvancedBiomedical Science-Legal Medicine Section, University of Naples “Federico II” Naples (Italy) - 5Department of Law, Economics andmathematical Methods, University of Sannio, Benevento (Italy)

Introduction

The spinal epidural hematoma is a rare butvery dangerous pathological condition involvingsevere neurological deficits, frequently describedafter spinal cord injuries(1-6).

The spinal surgery, the epidural anesthesia andanalgesia, the implantation of spinal cord stimula-tors and the chiropractic manipulations are some-times related to a spinal, post-operative,hematoma(7-18).

In addition, vascular malformation, coagu-lopathies, syringomielia and spinal cord tumors rep-

resent, with the pregnancy and the delivery, wellknown risk factors for a spontaneous spinal epidur-al hematoma(19-23).

The occurrence of spinal epidural hematomaafter cardiac or aortic surgery is very rare.

In this report, we describe the case of a 59-year-old man, who developed a spinal epiduralhematoma after a replacement of the descendingthoracic aorta with Sulzer Vascutek straight pros-thetic implant 30mm Ø for thoraco abdominal aor-tic dissection starting from aortic isthmus, to car-refour. table

Acta Medica Mediterranea, 2017, 33: 1163

Received December 30, 2016; Accepted June 20, 2017

ABSTRACT

The Authors report a case of acute spinal epidural hematoma after the descending aorta repair for thoracic-abdominal aorticdissection with Sulzer-Vascutek straight prosthetic implant. Left anterolateral thoracotomy in the fourth intercostal space was done.

After aneurysmectomy and straight aortic prosthetic implant a significant bleeding was observed. It needed clamping of the straight aortic prosthesis and redoing of the distal anastomosis 2 cm down stream.In II postoperative day the patient presented a spinal epidural hematoma with paraplegia. The authors analize the genesis of the hematoma, they bring back to literature review and recall the need for appropriate

maneuvers and appropriate procedures to avoid the onset of this severe medullary damage.

Keywords: Spinal epidural hematoma, cardio aortic surgery, medicolegal correlation.

DOI: 10.19193/0393-6384_2017_6_182

Case report

Z.C, 59 years old male, obese (BMI 30.50),with history of miococardial infarction (IMA). InSeptember 2001 was operated on for replacementof the ascending aorta with Vascutek 30 mm pros-thesis, for chronic dissection of the ascending aorta,type I De Bakey.

In November 2004 TC Thoraco-abdominalexamination showed a large thrombotic aneurysmof the Aorta (DT: about 8 cm), extending from theaortic arch to the thoracic-abdominal passage.

The aortic dissection involved the wholecourse of the vessel, up to the common left iliacartery. No pulmonary parenchymal consolidations,nor pleural effusion were present. There was noascites.

The aortography confirmed the dissectedaneurysm of thoracic aorta from the isthmus up tothe carrefour. The iliac arteries were perfused; theleft renal artery was not visible.

Coronary examination did not show any sig-nificant lesions. Left ventricular hypertrophy withmoderate aortic valve failure was observed at theecocolordoppler.

In April 2005, the chest x-ray examinationshowed a widespread accentuation of the pul-monary parenchymal texture and left basal dysven-tation. The Ecocolordoppler showed a dilated andhypertrophic left ventricle with a global functionpreserved in the absence of asymmetries of regionalkinetics, a mild ascending aorta dilatation, a mild tomoderate aortic regurgitation. Fine and mobilemitral valve, with flowmetry within the limits, rightsections normal.

Surgery was performed with the help of Extra-Corporeal Circulation (CEC) with left femoro-femoral technique, systemic heparin, hypothermia(28° C), circulatory arrest and antegrade cerebralperfusion. Left anterolateral thoracotomy in the 4thintercostal space. After aneurysmctomy, the opera-tor proceeded to replace the left hemi-arch and thedescending thoracic aorta with the interposition ofa single straight prosthesis, type Sulzer Vascutek 30mm Ø with terminal - terminal technique. CEC wasresumed after 34 minutes of circulatory arrest andthe patient was rewarmed.

Because of bleeding, the straight aortic pros-thesis was clamped and they redid the distal anasto-mosis, 2 cm downstream, without modifying thesurgical access from the 4th intercostal space, usingthe Finocchietto rib retractor. Declamping was per-

formed after 18 minutes. After, decannulation,hemostasis, two thoracic drainage and closure ofthe surgical wound. During surgery were transfused16 pockets of O Rh positive blood, 4 FrozenPlasma Units + 1 Platelet Pool unit.

Anesthetic induction and maintenance wasaccording to routine. Pre-CEC phase was character-ized by stable hemodynamics, without inotropicsupport. EGA slightly hypoxic for patient inmonopulmonary ventilation.

During CEC, stable hemodynamics, CECarrest. Brain perfusion during 30 min. Rhythmrecovery in Ventricular Fibrillation. After DCshocks, return to Sinus Rhythm. CEC exit withDOPAMINE. Sufficient diuresis, after stimulationwith furosemide and mannitol. Bleeding content.

In Intensive Care Unit, appropriateHemodynamic with DOPAMINE. On the first post-operative day, the patient was awake and coopera-tive but paraplegic.

In the second post-operative day, an MRI ofthe spinal cord was performed with gadolinium, itshowed a blood collection intracanal, extra-medullary, of about 1.5 mm in diameter, located inthe dorsal and cervical space (see Figure 1). Thecollection “appeared” in continuity through theforamen of D6-D7 left conjugation with volumi-nous peri-aortic blood collection.

The spinal cord was clearly marked and dis-placed to the right and an extension of the ependi-mal channel in the medullary above and below por-tions was observed. Given the time since theappearance of paraplegia (about 48 hours) for non-optimal respiratory and cardiovascular conditions

1164 Vacchiano Giuseppe, Tecchia Livio Benedetto et Al

Figure 1: MRI on T2 weighted (panel a) and T1 weigh-ted (panel b): a large epidural hematoma in cervico-dor-sal space with compressive effect on spinal cord.

of the patient, and the risks associated with theoperation, hematoma was not treated surgically.

On the sixth postoperative day, the patient wastransferred to a rehabilitative environment with adiagnosis of spinal extradural hematoma. He hadparaplegia of the lower limbs with bilateral tendonareflexia, anesthesia below D5-D6.

The thoracic TC (see Figure 2) referred: “arte-rial aortic irregularities in the reported outcomes.Residual collection around the descending aorticarch portion; at the same level, fracture results areappreciated in the posterior tracts of some coastalarches and the left transverse processes of the cor-responding dorsal vertebrae”.

The patient was discharged after 3 months andsent to home with the diagnosis of “flaccid paraple-gia from D6-D7 hematoma as result of aneurysmec-tomy and prosthetic reconstruction of proximaldescending aorta. Nervous bladder and intestine.Predominantly restrictive dys-ventilatory deficit”.

Discussion

Literature review report that epiduralhematoma is generally post-traumatic or post-oper-ative; the spontaneous occurrence is less frequent;in a third of case, no etiological factors can be iden-tified(24), but many cases are defined as spontaneousin the absence of in-depth analysis. Spinal epiduralhematoma has been also described after coronaryangiography by capillary oozing(25) and in aorticcoartation complicated with spinal artery aneurismrupture(26).

The presence of epidural spinal hematoma in apatient undergoing epidural catheterism was alsoreported by Shroll et al, after Collis-Nissen fundo-plication(27).

Recently has been remembered a risk of spinalhematoma in patients undergoing cardiovascularsurgery with a paravertebral catheter(28) and a sys-tematic review of the literature with a meta-analysisof the available randomized studies identified atotal of 25 epidural hematomas after 88820 epiduralanalgesia procedures producing an estimated risk of1:3552(29). The risk calculation does not justify notoffering epidural analgesia in cardiac surgery(30).

Rosen has described a spinal hematoma in anadolescent subjected to an aortic valve replacementfor aortic stenosis with associated epidural analge-sia; the patient’s coagulation system was altered(PTT 87.4 sec) and thrombocytopenia developedthree days after(31).

Spinal epidural hematoma following cardio aortic surgery: any correlation possible? 1165

Figure 2: Fracture of the posterior arc of the fiurth costawith an endopleuric and periaortic bleeding.

Table 1: Spinal hematomas after cardiac andaortic surgery.

A similar case was described by Bang(32): a 55-years-old man, subjected to combination of generalanesthesia with thoracic epidural analgesia for amitral valve replacement with associated tricuspidanular plasty, post-operatively the patient presentedPTT level at 42.2 sec, and his platelet was 77.000mm3.

Only six cases of spinal hematoma after car-diac or aortic surgery, without spinal catheterism,are reported in the literature(33-38) (Table 1).

Cardiac surgery was performed for mitralvalve(4) (two stenosis, one insufficiency, one pro-lapse), aortic stenosis and aortic aneurysm(1). In onecase, aortic coronary bypass was associated withaortic valve replacement.

In the cases reported in the literature, the rup-ture of the vertebral venous plexus of Batson,because of increased venous pressure, is reported asa possible cause of spinal hematoma.

The chronic pulmonary heart with pulmonaryhypertension and systemic venous hypertension hasbeen frequently observed.

The anticoagulant therapy, the dilution coagu-lopathy during cardiopulmonary surgery and theadvanced age were considered contributing factorsfor the development of the spinal hematoma.

In the described case, the spinal hematomawas related not to an increased venous pressure, butto unusual serious adverse event of the aorticsurgery: the breakage of the transverse processes ofleft D5-D6 and the corresponding ribs in their rearsection (see Figures 2 and 3).

These lesions were produced during the phas-es of surgery in an attempt to better control theoperation field. In fact, after the distal suture per-formed between prosthetic tube and the descendingthoracic aorta, there was a considerable bleeding

and the surgeon, who had practiced a thoracotomyat the fourth intercostal space, had an urgent need toimprove the visibility of the surgical field in theobese patient. He then carried out an accentuateddivarication of the left thoracic ribs with the retrac-tor, Finocchietto type, causing their fracture and thedistorsion/fracture of the transverse processes of theD6-D7 vertebrae.

Intercostal and peripheral vascular vessels andespecially connective fibrous structures that coatthe spine and separate the medullary channel fromthe chest cavity were also affected. A blood collec-tion, therefore, invaded the vertebral canal where itproduced an epidural hematoma.

It should be noted, moreover, that duringsurgery the patient was anticoagulated (systemicheparin 1 mg per Kg) due to extracorporeal circula-tion, and this condition favored blood loss and thespinal hematoma formation.

After a descending aortic thoracic repair,Biglioli and coworkers(34) reported a similar case: Aspinal compression with paraplegia was caused byhematoma and hemostatic gauze penetrated into thevertebral canal, following aggressive hemostaticmaneuvers at the posterior edge of thoracotomy,near the intervertebral foramen.

The posterolateral thoracotomy in factinvolves difficulties in ensuring hemostasis directlyat the beginning of the cost-vertebral junction andthe maneuvers to ensure a good vision of the surgi-cal field and a good hemostasis can atypical pro-duces pleural-epidural or pleural-subarachnoidcommunications.

The muscle-osseous barrier protecting thespinal cord is not very strong and can be easilybreak-down.

After pulmonary lobectomy or pneumonecto-my with posterolateral thoracotomy, similar epidur-al hematomas have been described(39-40).

Generally, the sudden onset of excruciatingback - pain is the first sign of a spinal hematomafollowed by significant motor and sensorial disor-der related to the level of spinal cord involvement.

When this condition is suspected, an earlydiagnosis and a rapid spinal cord decompression areneeded to avoid irreversible neurological damages.

In our case, in the immediate post-operativeperiod, the patient was assisted into the IntensiveCare Unit: was intubated and under analgesicdrugs; the hemodynamic was sustained withDopamine. So the paraplegia was highlighted onlythe day after, when the tracheal extubation was car-


Figure 3: Periaortic and bilateral endopleuric blood col-lection more evident in the left hemitorax. Callus forma-tion at posterior arc level of the sixth costa.

ried out. Then the patient received a conservativetherapy because the operational risk was estimatedvery high. The medullary hematoma was likely pro-duced during the operation of aortic repair, but theliterature indicates the possibility that the spinalhematoma can also occur at the time postoperative-ly from 1 hour(36) up to 60 hours after surgery(38).

Relative to the hematoma site, in our case andin the Biglioli report(34), endomidollary blood collec-tion was contiguous to cost-vertebral lesions (D6-D7), while in the cases described in the literature,spinal hematoma was highlighted at different levels(cervical, dorsal and lumbar), also at distant sitefrom the main surgical procedure, and was relatedto increased venous pressure in such vertebral dis-tricts with rupture of the internal vertebral venousplexus of Batson(41).

Yamada et al. suggesting, as a risk factor forpostoperative spinal epidural hematoma, a highincrease in blood pressure after extubation (50mmHg or more) and a High Body Mass Index(42).

A history of hypertensive disease or transitoryhypertensive status after surgery was taken over byYin in patients underwent an open cervical spinalsurgery who developed a postoperative spinalepidural hematoma(43).

Element of great interest in the genesis of thehematoma are also the times of surgery and theinfusion therapy. CEC long times may produceindeed, alteration in coagulation factors and theadministration of crystalloids can dilute thepatient’s plasma: so the hemostasis is impaired withpossible consistent hemorrhage.

In our case, the patient during the operation,which lasted over eight hours, received sixteenblood packets (O Rh+), three concentrated erythro-cytes, four frozen plasma units and one PlateletPool unit.

In a case reported by Martin(41), the patient dur-ing a spinal surgery, lasted 5 hours, received crys-talloids (10 L) and two units of packed red cells. Atthe end of the surgical procedure, he developed adilution coagulopathy, hemoglobin levels droppedto 6.3 g/L and the prothrombin time rose to 57.5sec. A hemorrhage with spontaneous spinalhematoma and paraplegia was observed at a sitedistant from the surgical procedures. In thoracicaortic surgery, paraplegia is a not uncommon com-plication(44) and recently new techniques have beensuggested to prevent it(45). Generally, it is deter-mined by a medullary ischemia consequent to thedescending thoracic aorta cross-clamping, down-

stream of the left subclavian artery emergency.Following the clamping carried out, to make

bloodless surgical field, the arteries that feed thespinal cord, as the artery of Adamkiewicz, mayexperience a long time of ischemia, or be affectedby cholesterol emboli resulting medullary suffering.

In our case, however, paraplegia was causednot by ischemia, but by a medullary hematoma, fol-lowing the incongruous use of a coastal retractor,thus constituting an obvious malpractice’s case.

Conclusions

In cardio aortic surgery, in addition to compli-cations related to a pathology(46-48), it should be keptin mind the possible occurrence of spinal hematomaand intervene on time and in the most appropriateways to avert this possibility and timely release thespinal cord from hematoma.

The presence of a possible paraplegia shouldbe investigated in the immediate postoperative peri-od. The rapid progression of symptoms, related tothe amount of bleeding, is burdened with a worseprognosis, while the late evidence hematoma can becorrelated to a minor bleeding entity, slower andwith better chances of recovery.

Decompression laminectomy must be per-formed quickly within 8 to 12 hours to be effective,but it is not always possible to carry out suchsurgery. Moreover, paraplegia often did notimprove despite surgical decompression(49-51): thespinal cord is a particularly delicate and sensitivestructure and sometimes also simple routine opera-tions can compromise its functionality even withoutnoticeable morphological alterations(52).

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_________Corresponding authorPROF. SERAFINO RICCI, M.D. Department of Anatomy, Histology, Legal Medicine andOrthopedics - “Sapienza” University, RomeViale Regina Elena 33600161 Rome(Italy)


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