Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics.<sup>39 Tryba M. Rückmarksnahe regionalanästhesie und niedermolekulare heparine: Pro Anasthesiol Intensivmed Notfallmed Schmerzther 1993 ;  28 : 179

Cliquez ici pour aller à la section Références</sup> Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus.

Although hemorrhagic complications can occur after virtually all regional anesthetic techniques, bleeding into the spinal canal is perhaps the most serious hemorrhagic complication associated with regional anesthesia because the spinal canal is a concealed and nonexpandable space. Spinal cord compression from spinal hematoma may result in neurologic ischemia and paraplegia. Spinal hematoma may occur from vascular trauma from needle or catheter placement into the subarachnoid or epidural space. However, it may also occur in association with neoplastic disease or preexisting vascular abnormalities. Of special interest to the anesthesiologist are those spinal hematomas that have occurred spontaneously with or without the presence of antiplatelet or anticoagulation therapy. Over 100 spontaneous epidural hematomas have been reported, 25% of which are associated with anticoagulation therapy.<sup>38 Spurny O.M., Rubin S., Wolff J.W. , et al. Spinal epidural hematoma during anticoagulant therapy Arch Intern Med 1964 ;  114 : 103

Cliquez ici pour aller à la section Références</sup>

In a review of the literature between 1906 and 1994, Vandermeulen et al<sup>41 Vandermeulen E.P., Van Aken H., Vermylen J. Anticoagulants and spinal-epidural anesthesia Anesth Analg 1994 ;  79 : 1165

Cliquez ici pour aller à la section Références</sup> reported 61 cases of spinal hematoma associated with epidural or spinal anesthesia. In 42 of the 61 patients (69%), the spinal hematomas associated with central neural blockade occurred in patients with evidence of hemostatic abnormality. Twenty-five of the patients had received intravenous or subcutaneous heparin, while an additional five patients were presumably administered heparin as they were undergoing a vascular surgical procedure. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran. Seventy were treated immediately before or after the spinal or epidural anesthetic. Needle and catheter placement were reported to be difficult or bloody in 15 (25%) patients. Thus, in 53 of the 61 cases (87%), either a clotting abnormality or needle placement difficulty was present. Neurologic compromise presented as progression of sensory of motor block or bowel/bladder dysfunction, not severe radicular back pain. Importantly, although only 48% of patients had partial or good neurologic recovery, spinal cord ischemia tended to be reversible in patients who underwent laminectomy within 8 hours of onset of neurologic dysfunction (Table 1).

In order to reduce the risk of spinal hematoma associated with central neural blockade, it is necessary to understand the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and also the clinical studies involving patients undergoing central neural blockade while receiving these medications. Recommendations for regional anesthetic management follow the consensus statements on Neuraxial Anesthesia and Anticoagulation published by the American Society of Regional Anesthesia.<sup>9 Enneking K.F., Benzon H.T. Oral anticoagulants and regional anesthesia: A perspective Reg Anesth Pain Med 1998 ;  23 : 140  [cross-ref]

Cliquez ici pour aller à la section Références, 18 Horlocker T.T., Wedel D.J. Neuraxial block and low molecular weight heparin: Balancing perioperative analgesia and thromboprophylaxis Reg Anesth Pain Med 1998 ;  23 : 164  [cross-ref]

Cliquez ici pour aller à la section Références, 21 Liu S.S., Mulroy M.F. Neuraxial anesthesia and analgesia in the presence of standard heparin Reg Anesth Pain Med 1998 ;  23 : 157  [cross-ref]

Cliquez ici pour aller à la section Références, 34 Rosenquist R.W., Brown D.L. Neuraxial bleeding: Fibrinolytics/thrombolytics Reg Anesth Pain Med 1998 ;  23 : 152  [cross-ref]

Cliquez ici pour aller à la section Références, 40 Urmey W.F., Rowlingson J.C. Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth Pain Med 1998 ;  23 : 146  [cross-ref]

Cliquez ici pour aller à la section Références</sup> Although this article will deal mainly with continuous techniques of major conduction blocks and anticoagulants, the same principles apply to all regional anesthetic techniques.