Lagerkranser Michael, Lindquist Christer
Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
Clinical neurosciences, BUPA Cromwell Hospital, 164-178 Cromwell Road, London, SW5 0TU, U.K.
Scand J Pain. 2017 Apr;15:130-136. doi: 10.1016/j.sjpain.2016.11.009. Epub 2017 Mar 17.
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs, neurological injury associated with SH has the worst prognosis. Around the turn of the millennium, the first guidelines aiming to reduce the risk of this complication were published. These guidelines are based on known risk factors for SH, rather than evidence from randomized, controlled trials (RCTs). RCTs, and hence meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing data from a significant number of published case reports of rare complications may reveal risk factors and patterns undetectable in reports on occasional cases, and can thereby help to improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015 with regard to diagnosis, treatment, and outcome of SH after CNB.
MEDLINE and EMBASE were utilized to find case reports published in English, German, or Scandinavian languages between 1994 and end of 2015, using appropriate search terms. Reference lists were also scrutinized for case reports. We documented initial and worst symptoms and signs of SH, diagnostic methods, treatment, and outcome of the SH. We calculated occurrences in per cent using the number of informative reports as denominator.
One hundred and sixty-six case reports on spinal hematomas after CNB published during the years between 1994 and 2015 were identified. Eighty per cent of the patients had severe neurological symptoms (paresis or paralysis). When compared over time, outcomes have improved significantly. Among patients subjected to surgical evacuation of the hematoma, outcomes were best if surgery was performed within 12hours from the first sign of motor dysfunction. However, even patients operated after more than 24hours had relatively favourable outcomes. Whereas the outcomes after surgical evacuation of the epidural haematomas were quite satisfactory, only one of the operations for subdural haematoma (SSDH) resulted in a favourable outcome.
Suspicion of a spinal hematoma calls for the consultation of an orthopaedic or neurological surgeon without delay. MRI is the recommended diagnostic tool. Surgical evacuation within 12h from the first sign of motor dysfunction seems to lead to the best outcome, although many patients operated as late as after more than 24hours did regain full motor function. Despite the poor prognosis after surgical evacuation of SSDH, the outcomes after post-CNB spinal haematoma in general have improved significantly over time.
椎管内出血导致脊髓血肿（SH）是中枢神经轴索阻滞（CNB）一种罕见但严重的并发症。在CNB的所有严重并发症中，与SH相关的神经损伤预后最差。在千年之交，旨在降低这种并发症风险的首个指南发布。这些指南基于已知的SH风险因素，而非来自随机对照试验（RCT）的证据。RCT以及RCT的荟萃分析并不适合识别罕见事件。分析大量已发表的罕见并发症病例报告的数据，可能会揭示偶尔病例报告中未发现的风险因素和模式，从而有助于改善CNB的管理。本综述的目的是分析1994年至2015年间发表的关于CNB后SH的病例报告，涉及CNB后SH的诊断、治疗及预后。
利用MEDLINE和EMBASE，使用适当的检索词查找1994年至2015年底以英文、德文或斯堪的纳维亚语言发表的病例报告。还仔细查阅参考文献列表以查找病例报告。我们记录了SH的初始及最严重症状和体征、诊断方法、治疗及SH的预后。我们以提供信息的报告数量为分母计算发生率（百分比）。
确定了1994年至2015年间发表的166例关于CNB后脊髓血肿的病例报告。80%的患者有严重神经症状（轻瘫或瘫痪）。随着时间推移进行比较，预后有显著改善。在接受血肿手术清除的患者中，如果在出现运动功能障碍的首个体征后12小时内进行手术，预后最佳。然而，即使在24小时后进行手术的患者也有相对良好的预后。硬膜外血肿手术清除后的预后相当令人满意，而硬膜下血肿（SSDH）的手术中只有一例预后良好。
怀疑脊髓血肿需要立即咨询骨科或神经外科医生。MRI是推荐的诊断工具。在出现运动功能障碍的首个体征后12小时内进行手术清除似乎能带来最佳预后，尽管许多在24小时后才进行手术的患者确实恢复了完全运动功能。尽管SSDH手术清除后的预后较差，但总体而言，CNB后脊髓血肿的预后随着时间推移有显著改善。
