Keser C, Groh J, Schramm W, Peter K
Institut für Anästhesiologie, Ludwig-Maximilians-Universität München, Klinikum Grosshadern.
Anaesthesist. 1996 Dec;45(12):1203-10. doi: 10.1007/s001010050359.
Spinal or intracranial haematoma is a rare but severe complication of spinal/epidural anaesthesia with an incidence of less than 1:100,000. Coagulation defects, traumatic puncture, and anticoagulant drugs are assumed to be risk factors for the development of this kind of haematoma. Whether the risk of bleeding after spinal/epidural anaesthesia is increased by the administration of low-dose heparin (unfractionated or fractionated) for thromboprophylaxis is currently under discussion.
A randomised, prospective trial answering this question is not feasible because of the rarity of the complication. As an alternative, we identified all case reports described in the literature to date and analysed them for possible risk factors. In conjunction with spinal/epidural anaesthesia, we found 4 cases of spinal and 2 cases of intracranial haematoma following treatment with unfractionated heparin and 6 cases of spinal haematoma following treatment with different low-molecular-weight (LMW) heparins. In none of these cases could thromboprophylaxis with heparin be identified as the only risk factor for bleeding: in 11 of the 12 cases a difficult or traumatic puncture was described. Eleven patients showed three or more possible risk factors, e.g., coagulation defects, concomitant therapy with other anticoagulant drugs, or anatomic abnormalities.
We suggest that the development of spinal or intracranial haematoma after spinal/epidural anaesthesia is a multifactorial event. An influence of low-dose heparin prophylaxis as a cofactor cannot wholly be excluded because of the difficulty of studying the problem in a prospective way. The few case reports have to be seen in the context of millions of patients who have received either unfractionated or LMW heparin and lumbar or thoracic regional anaesthesia without any complication. We conclude that low-dose heparin prophylaxis (fractionated or unfractionated) is not a definite contraindication to spinal/epidural anaesthesia. High-risk (ASA III/IV) patients in particular benefit from effective postoperative analgesia achieved by local anaesthetics in combination with effective heparin thromboprophylaxis. Nevertheless, the absolute contraindications for regional anaesthesia must be respected and an individual risk/benefit analysis should be performed for every patient. An adequate time interval between application of heparin and regional anaesthesia or removal of a spinal/epidural catheter, atraumatic puncture technique, and careful neurologic monitoring during the post-operative period can minimise the risk of complications.
脊髓或颅内血肿是脊髓/硬膜外麻醉罕见但严重的并发症，发生率低于1:100,000。凝血缺陷、穿刺创伤和抗凝药物被认为是此类血肿发生的危险因素。目前正在讨论，为预防血栓而给予低剂量肝素（普通肝素或低分子肝素）是否会增加脊髓/硬膜外麻醉后出血的风险。
由于该并发症罕见，因此开展一项回答此问题的随机前瞻性试验并不可行。作为替代方案，我们检索了迄今为止文献中描述的所有病例报告，并分析其中可能的危险因素。在脊髓/硬膜外麻醉的情况下，我们发现4例脊髓血肿和2例颅内血肿发生于普通肝素治疗后，6例脊髓血肿发生于不同低分子肝素治疗后。在这些病例中，均未发现肝素预防血栓形成是出血的唯一危险因素：12例中有11例描述了穿刺困难或有创伤。11例患者显示出三种或更多可能的危险因素，如凝血缺陷、同时使用其他抗凝药物或解剖异常。
我们认为，脊髓/硬膜外麻醉后脊髓或颅内血肿的发生是多因素事件。由于前瞻性研究该问题存在困难，因此不能完全排除低剂量肝素预防作为辅助因素的影响。在数百万接受普通肝素或低分子肝素以及腰段或胸段区域麻醉且未出现任何并发症的患者背景下，少数病例报告应予以考虑。我们得出结论，低剂量肝素预防（低分子肝素或普通肝素）并非脊髓/硬膜外麻醉的绝对禁忌证。尤其是高危（ASA III/IV级）患者，可从局部麻醉药联合有效的肝素预防血栓形成所实现的有效术后镇痛中获益。然而，必须遵守区域麻醉的绝对禁忌证，并且应对每位患者进行个体风险/获益分析。肝素应用与区域麻醉或拔除脊髓/硬膜外导管之间有足够的时间间隔、采用无创伤穿刺技术以及术后仔细的神经学监测可将并发症风险降至最低。
