PM&R
Volume 1, Issue 4 , Pages 389-396 , April 2009

Intraspinal Hematoma Following Neuraxial Anesthesia and Low-Molecular-Weight Heparin in Two Patients: Risks and Benefits of Anticoagulation

  • Douglas Elwood, MD, MBA

      Affiliations

    • Department of Physical Medicine and Rehabilitation, New York University, New York, NY⁎
    • Corresponding Author InformationAddress correspondence to: D.E., Rusk Institute of Rehabilitation Medicine, Suite 600, NYU Medical Center, 400 E 34th St, New York, NY 10016
    • ,
  • Caroline Koo, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, New York University, New York, NY†

Received 7 March 2008 ,Accepted 29 November 2008.

References 

  1. Kim S. Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997-2004. Arthritis Care Res. 2008;59:481–488
  2. Colwell C, Collis D, Paulson R, et al. Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty, evaluation during hospitalization and three months after discharge. J Bone Joint Surg. 1999;81:932–940
  3. Fitzgerald RH, Spiro TE, Trowbridge AA, et al. Prevention of venous thromboembolic disease following primary total knee arthroplasty. J Bone Joint Surg. 2001;83A:900–906
  4. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP Conference of Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3):338S–400S
  5. Heit JA, Melton LJ, Lohse CM, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clin Proc. 2001;76:1102–1110
  6. Comerota AJ, Chouhan V, Harada RN, et al. The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis. Ann Surg. 1997;226:306
  7. Thenganatt J, Geerts W. Prevention of venous thromboembolism in surgical patients: why and how?. Techn Reg Anesth Pain Manage. 2006;10:40–45
  8. Ferguson J. Low-molecular-weight heparins and glycoprotein IIb/IIIa antagonists in acute coronary syndromes (Part 1). J Invasive Cardiol. 2004;16:136–144
  9. Schafer AI. Low-molecular-weight heparin—an opportunity for home treatment of venous thrombosis. N Engl J Med. 1996;334:724–726
  10. Green D, Hirsh J, Heit J, et al. Low molecular weight heparin: a critical analysis of clinical trials. Pharmacol Rev. 1994;46:89–109
  11. Liu S, Mulroy M. Neuraxial anesthesia and analgesia in the presence of standard heparin. Reg Anesth Pain Med. 1998;23(6, suppl 2):157–163
  12. Hirsh J, Warkentin T, Shaughnessy S, et al. Heparin and low-molecular-weight heparin mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest. 2001;119:64S–94S
  13. Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med. 1995;332:1330–1336
  14. Lilikakis A, Papapolychroniou G, Michelinakis E. Thrombocytopenia and intra-cerebral complications associated with low-molecular-weight heparin treatment in patients undergoing total hip replacement (A report of two cases). J Bone Joint Surg. 2006;88:634–638
  15. Houde JP, Steinberg G. Intrahepatic hemorrhage after use of low-molecular-weight heparin for total hip arthroplasty. J Arthroplasty. 1999;14:372–374
  16. Shaieb MD, Watson BN, Atkinson RE. Bleeding complications with enoxaparin for deep venous thrombosis prophylaxis. J Arthroplasty. 1999;14:432–438
  17. Lassen M, Ageno W, Borris L, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008;358:2776–2786
  18. Harenberg J, Gnasso A, de Vries JX, et al. Inhibition of low-molecular-weight heparin by protamine chloride in vivo. Thromb Res. 1985;38:11
  19. Gaiser R, Berkowitz D, Chou D. Epidural blood patch in a patient taking enoxaparin. J Clin Anesth. 2004;16:386–388
  20. Moussallem C, Helou A, El-Yahchouchi C, et al. Epidural catheters, anticoagulation, and the risk of spinal hematoma: a review of the literature. Internet J Orthop Surg. 2007;6(2):http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijos/vol6n2/epidural.xmlAccessed August 30, 2008
  21. Wysowski D, Talarico L, Bacsanyi J, et al. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med. 1998;338:1774–1775
  22. Lang S. Spinal epidural hematoma: still an enigma. J Clin Anesth. 2004;16:317–319
  23. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient, defining the risks: the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation. Reg Anesth Pain Med. 2003;28:172–197
  24. Tryba M. Epidural regional anesthesia and low molecular heparin: Pro [in German]. Anaesth Intensivemed Notfallmed Schmerzther. 1993;28:179–181
  25. Weitz JI. Drug therapy: low-molecular-weight heparins. N Engl J Med. 1997;337:688–698
  26. Horlocker T, Wedel D. Neuraxial block and low-molecular-weight heparin: balancing perioperative analgesia and thromboprophylaxis. Reg Anesth Pain Med. 1998;23:164–177
  27. Hodgson PS, Liu SS. New developments in spinal anesthesia. Anesthesiol Clin North Am. 2000;18:235–249
  28. Douketis JD, Dentali F. Managing anticoagulant and antiplatelet drugs in patients who are receiving neuraxial anesthesia and epidural analgesia: a practical guide for clinicians. Techn Reg Anesth Pain Manage. 2006;10:46–55
  29. Litz R, Gottschlich B, Stehr S. Spinal epidural hematoma after spinal anesthesia in a patient treated with clopidogrel and enoxaparin. Anesthesiology. 2004;101:1467–1470
  30. Chan L, Bailin M. Spinal epidural hematoma following central neuraxial blockade and subcutaneous enoxaparin: a case report. J Clin Anesth. 2004;16:382–385
  31. Sidiropoulou T, Pompeo E, Bozzao A, et al. Epidural hematoma after thoracic epidural catheter removal in the absence of risk factors. Reg Anesth Pain Med. 2003;28:531–534
  32. Heppner P, Monteith S, Law A. Spontaneous spinal hematomas and low-molecular-weight heparin. J Neurosurg Spine. 2004;1:232–236
  33. Chaikin P, Lim J. Reply to correspondence, Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med. 1998;338:1774–1775
  34. Schroeder D. Statistics: detecting a rare adverse drug event using spontaneous reports. Reg Anesth Pain Med. 1998;23:183–189
  35. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest. 2001;119:132s–175s
  36. Horlocker TT. Thromboprophylaxis and neuraxial anesthesia. Orthopedics. 2003;26(2):S243–S249
  37. Kopp SL. Spinal hematoma. Semin Pain Med. 2004;2:237–243
  38. American College of Chest Physicians. ACCP Consensus Committee on Pulmonary Embolism: Opinions regarding the diagnosis and management of venous thromboembolic disease. Chest. 1998;113:499–504
  39. Agnelli G, Piovella F, Buoncristiani P, et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med. 1998;339:80–85
  40. Eriksson B, Borris L, Friedman R, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358:2765–2775

 Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org

PII: S1934-1482(08)00039-7

doi: 10.1016/j.pmrj.2008.11.012

PM&R
Volume 1, Issue 4 , Pages 389-396 , April 2009

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