CASE REPORT
An Epidural Hematoma in an Adolescent Patient After
Cardiac Surgery
David A. Rosen, MD*†, Denzil W. Hawkinberry II, MD*, Kathleen R. Rosen, MD*†,
Robert A. Gustafson, MD†‡, Jeffery P. Hogg, MD§, and Lynn M. Broadman, MD*†
Departments of *Anesthesiology, †Pediatrics, ‡Surgery, and §Radiology, West Virginia University Children’s Hospital,
West Virginia University School of Medicine, Morgantown
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An 18-yr-old patient had a thoracic epidural placed un-
der general anesthesia preceding an uneventful aortic
valve replacement with a bioprosthetic valve. On the
second postoperative day, he was anticoagulated and
also received an antithrombotic medication. While am-
bulating, he experienced pain in his back, and there was
E
pidural analgesia for pediatric cardiac surgery
has been described in the anesthesia literature
(1– 4). No epidural hematomas have been re-
ported in these patients that could be attributed to the
use of epidural catheters, subsequent heparinization,
or maintenance of epidural analgesia into the postop-
erative period. Several authors have attempted to doc-
ument the safety, efficacy, and benefits of periopera-
tive epidural analgesia in these patients (1– 4).
In this case report, we present an epidural hema-
toma related to epidural analgesia in an adolescent
who underwent cardiac surgery.
Case Report
An 18-yr-old, 67-kg man presented for bioprosthetic replace-
ment of his aortic valve, secondary to aortic stenosis. Four
years earlier, he successfully underwent an aortic valvot-
omy, with a perioperatively placed caudal epidural used for
perioperative analgesia without complication. Because of his
intense fear of needles and concerns about pain, general
anesthesia was induced via mask before the insertion of any
needles, as in his previous surgery. The epidural catheter
(20-gauge, unstyleted, closed tip, radiopaque, and poly-
amide) was inserted in the T9-10 interspace and advanced 3
cm. Aspiration for blood or cerebrospinal fluid was nega-
tive. Injection of a 3-mL test dose (1.5% lidocaine with
Accepted for publication October 8, 2003.
Address correspondence and reprint requests to David A. Rosen,
MD, Robert C. Byrd Health Science Center, West Virginia Univer-
sity School of Med, PO Box 9134, Morgantown, WV 26506-9134.
Address e-mail to rosend@rcbhsc.wvu.edu.
DOI: 10.1213/01.ANE.0000103267.37895.5B
966 Anesth Analg 2004;98:966–9
blood in his epidural catheter. The catheter was re-
moved, and he developed motor and sensory loss.
Rapid surgical decompression resulted in recovery of
his lost neurological function. Management and strate-
gies for preventing this problem are discussed.
(Anesth Analg 2004;98:966 –9)
1:200000 epinephrine) produced no change in heart rate or
arterial blood pressure. Three hours later, the patient re-
ceived 21,000 U of heparin in preparation for cardiopulmo-
nary bypass (CPB).
Upon completion of the valve replacement and after meas-
ured reversal of heparin with protamine (Rapid point Ac-
cent™, Bayer Corporation, East Walpole, MA) a double-
lumen, peripherally inserted central venous catheter (PICC)
was placed. The patient was transported to the pediatric
intensive care unit (PICU) and tracheally extubated. A con-
tinuous epidural infusion of preservative free hydromor-
phone (3.0 ␮g · kg⫺1 · h⫺1) and 0.75% lidocaine (10
␮g · kg⫺1 · min⫺1) was used for postoperative analgesia.
Postoperative day one was uncomplicated. The patient
reported adequate pain control and ambulated without dif-
ficulty with the epidural catheter still in place. At 49 h after
surgery, the PICU staff initiated IV heparin therapy for
thrombo-prophylaxis for the prosthetic aortic valve. An ini-
tial IV bolus of 4500 U of heparin was followed by a contin-
uous heparin infusion. Neither the anesthesiologist nor the
surgeon were notified of this decision. Approximately 5 h
later (53 h after surgery), the PICC line became dysfunc-
tional, and each lumen was flushed with 2 mg of the throm-
bolytic drug alteplase. Within 2 h (57 h after surgery), while
ambulating, the patient reported intense back pain. There
was blood in the epidural catheter and at the catheter inser-
tion site; the PICU team immediately removed the epidural
catheter. The activated partial thromboplastin time (aPTT)
value obtained from a blood sample at that time was 87.4 s
(Table 1).
On removal of the epidural catheter, there was the sudden
onset of numbness and weakness distal to T9. The anesthe-
siologist was contacted. Heparin therapy was then discon-
tinued, a computed tomographic (CT) scan was obtained,
and the spine surgery service was consulted. The initial CT
imaging was inconclusive, requiring a magnetic resonance
imaging (MRI) scan. The CT scan was obtained because it
©2004 by the International Anesthesia Research Society
0003-2999/04
ANESTH ANALG CASE REPORT 967
2004;98:966 –9

Table 1. Hematologic Values and Their Temporal Relationship with the Epidural Hematoma Formation
Postoperative time Hematocrit Platelet count Activated partial
Event (h:min) (%) (thousand) thromboplastin time
40:10 32 127
Heparin therapy initiation 49:30
58:30 87
Alteplase 57:00
Back pain, Blood in catheter 57:45
Catheter removed, paresis 58:15
Preoperative lab work 60:53 35 76 38.1
Surgical decompression 61:30
64:25 23.7 107 24.0
72:00 24.7 177 —
85:01 23.3 164 —

was immediately available; additionally, we believed that

the MRI scanner’s magnet might heat the patient’s sternal
wires and cause discomfort. In fact, the MRI scan was
aborted before it was 50% complete because of the patient’s
complaints of severe burning in his chest from his sternal
wires being heated by the MRI magnet. However, MRI
imaging confirmed the diagnosis of an epidural hematoma,
and the patient was taken directly to the operating room for
urgent decompressive laminectomy (Fig. 1).
Five hours from the onset of neurologic symptoms, the
patient underwent surgical evacuation of the hematoma,
which extended from the T8 to T11 levels. Intraoperatively,
the patient received a platelet transfusion and a 30-mg/kg
bolus of methylprednisolone. A methylprednisolone infu-
sion was continued, as per our spinal cord injury protocol, at
a rate of 5.4 mg · kg⫺1 · h⫺1 for 72 h. Twenty-four hours
postlaminectomy, the patient demonstrated mild residual
lower extremity motor and sensory deficits. Six weeks later,
his neurological examination had returned to normal.

Discussion
This patient developed a postoperative epidural hematoma
related to epidural analgesia and concomitant anti-
coagulant/thrombolytic therapy, resulting in an additional
surgery and temporary neurological dysfunction.
Guidelines for use of neuroaxial techniques in pa-
tients receiving anticoagulants were published in 2003
(5). The role of epidural anesthesia/analgesia in pa-
tients undergoing cardiothoracic surgery is still a de-
batable subject. However, several published reports
have attempted to document the safety of this tech-
nique in pediatric (1– 4) and adult (6 –9) patients un-
dergoing surgery requiring intraoperative anticoagu-
lation. In 1995, Flandin-Blety and Barrier (10) reported
a review of more than 24,000 noncardiac pediatric
patients who received an epidural anesthetic/
analgesic, and only five complications related to the
technique were reported, none of which were epidural
hematoma formation.
Much of the argument against using spinal or epidural
anesthesia in patients who have received or will receive
heparin therapy is derived from the Ruff and Dougherty
Figure 1. Preoperatively, a dorsal intraspinal hematoma extends
from T9 through T10 with anterior displacement and compression
of the spinal cord. These findings were consistent with the patient’s
sensory and motor loss below the umbilicus.
1981 report (11) of 342 patients undergoing lumbar punc-
ture followed by systemic heparinization. In this report, 7 of
342 (2%) patients developed a spinal hematoma.
There are no reports of spinal hematoma related to
neuraxial anesthesia in patients undergoing CPB, nor
are there any closed claims on file in the registry (5).
However, with ⬍1500 reports of the safe use of epi-
dural anesthesia in children undergoing systemic he-
parinization for CPB, and only 30% of these thoracic
(1– 4), the total sample size lacks statistical power to
make a definitive statement regarding the safety of
this technique (Type II error). Based on Tryba’s (12)
estimates of the incidence of spinal/epidural hema-
toma formation in nonanticoagulated patients receiv-
ing epidural (1:150,000) or spinal (1:220,000) anesthe-
sia, a sample of nearly 200,000 patients would be
968 CASE REPORT
required for 80% power to detect a 10-fold increase in
the incidence of this complication (13). A mathemati-
cal analysis by Ho et al. (14), based on the 4583 epi-
dural and 10,840 spinal anesthetics reported in cardiac
patients, estimate the risk of epidural hematoma for-
mation to be no more than 1:1528 for epidurals and
1:3610 for spinals. Thus, there is insufficient data to
conclude that preoperative placement of an epidural
catheter followed full heparinization one to three
hours later is risk free (1–3).
The benefits of regional anesthesia in adult and pedi-
atric cardiac surgery patients are well documented (1–
4,15–19). Nader et al. (18) described multiple potential
respiratory advantages of regional techniques, which are
as follows: (a) perioperative respiratory depression was
decreased when compared with IV narcotic therapy; (b)
earlier extubation; and (c) lower postoperative Pco2.
Epidural hematoma, although rare, is a potentially
devastating complication. In 1994, Vandermeulen et
al. (20) reported 61 cases of epidural hematoma for-
mation related to neuraxial anesthesia between 1906
and 1993. An epidural technique was used in 46 of 61
(69.5%) of these anesthetics; the remaining patients
received a spinal anesthetic. An epidural catheter was
used in 32 of 46 (66%) of these patients. The epidural
bleeds occurred upon removal of the epidural catheter
in 15 of 32 (47%) of these patients. More importantly,
42 of 61 (68%) of the epidural hematomas reported by
Vandermeulen et al. (20) occurred in patients with
impaired coagulation.
This patient’s coagulation system was altered in
several ways. The aPTT at the approximate time of
hematoma formation was 87.4 seconds (normal range,
24.8 –37.3). Approximately one hour after receiving a
4-mg injection of alteplase into the PICC line, neuro-
logic symptoms consistent with epidural hematoma
formation were noted. Thrombocytopenia developed
three days after intraoperative exposure to CPB and
heparin and was diagnosed approximately 12 hours
after initiation of postoperative heparin therapy via a
blood sample obtained for the prelaminectomy coag-
ulation profile. At that time, the platelet count was
76,000. Whether the thrombocytopenia was surgery
related or rapid onset nonantibody-mediated heparin-
induced thrombocytopenia and thrombosis syndrome
(21) is unknown. Antibody-mediated heparin-induced
thrombocytopenia and thrombosis syndrome usually
occurs approximately five days after exposure to hep-
arin (22). In this case, all screening tests for heparin-
induced antiplatelet antibodies were negative.
This patient’s first symptom was severe radicular
back pain; this is but one way in which the onset of
epidural hematoma symptoms can initially present.
New onset muscle weakness (46%), back pain (38%),
sensory deficit (14%), and urinary retention (8%) are
all reported as possible initial signs and symptoms of
epidural hematoma (20). Interestingly, this patient
ANESTH ANALG
2004;98:966 –9
presented with back pain yet remained neurologically
intact until after the epidural catheter was removed.
We hypothesize that blood loss through the epidural
catheter helped to decrease the pressure effects of the
developing hematoma. The same progression of
symptoms may have been observed over a longer
period of time if the catheter had not been extracted.
The only effective treatment for a compressing epi-
dural hematoma is decompressive laminectomy with
evacuation of the hematoma (20). Final neurologic
outcome depends on: (a) the speed with which the
hematoma develops; (b) the severity of the preopera-
tive neurological deficit; (c) the size of the hematoma;
and (d) the time between hematoma formation and
surgical evacuation (20,23,24). In patients with good
neurologic outcomes, decompression occurs within
eight hours of the initial development of neurologic
signs or symptoms (20).
Epidural analgesia offers many potential benefits in
the treatment of postoperative pain compared with
parenteral opiates. An alert comfortable patient is able
to change position, cough, and ambulate. These ad-
vantages prevail, even if the epidural catheter can only
be maintained for 24 – 48 hours, because the effects can
last long after the catheter is removed. There are like-
wise some rare but significant potential complications
in the patient who has had a prosthetic valve placed.
The risks and benefits must be reviewed for each
patient. The risk of potential life-threatening hemor-
rhage after anticoagulation is so great in children that
a prosthetic valve must be avoided if at all possible.
When a prosthetic valve is the only option, a biopros-
thetic valve may be chosen as a way to minimize the
need for long-term anticoagulation. Management of
pediatric cardiac surgery patients involves several
care teams, and communication among all providers is
vital. All providers must understand the potential for
hematologic complications in these patients.
In summary, this case report documents the occur-
rence of a postoperative epidural hematoma in a pa-
tient whose coagulation system was altered during
surgery and after surgery with heparin and the throm-
bolytic drug alteplase. Additionally, postoperative
thrombocytopenia was present, further contributing
to derangement of his coagulation system. These fac-
tors contributed to the development of an epidural
hematoma on postoperative Day 2. More importantly,
removal of the epidural catheter in the presence of
impaired hemostasis may have increased the bleeding
and further compounded the problem.
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CASE REPORT 969
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