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Haematoma and abscess after epidural analgesia
- Manesh Mathews, Nottingham. NG7 2UH (10 September 2008)
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Haematomas and abscesses related to epidural analgesia
- James H Low (2 September 2008)
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Manesh Mathews, SpR Anaesthesia and pain management University Hospital NHS Trust, Nottingham. NG7 2UH
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Sir I read with interest the recent article about epidural haematoma and abcess and also the response from Dr James Low. 1. While there is an increase in awareness about this rare but catastrophic condition the fact remains that we still do not know the true extent of this problem. A review of literature by Mackenzie et al 1 estimated the incidence of spinal epidural abcess in all hospital admissions as 0.2 – 2.0/10,0002,3 and a peak incidence in 6th and 7th decades of life3,4. Postoperative epidural abscesses account for 16% of all epidural – spinal abscesses2 and epidural catheter is a recognised predisposing factor5. In the series by Baker et al2 haematogenous route of spread was identified in 26% of cases, the sources of bacteraemia being furuncles, pharyngitis and dental abscesses. Blunt trauma is another predisposing factor and it is postulated that trauma may result in the formation of epidural haematoma which can subsequently get infected. The direct spread of infection into the epidural space from a source adjacent to spine like spondylitis or discitis has also been described6. My point is that not all post operative spinal abcesses can be ascribed to epidural, and that the abscess can be purely coincidental, more so since we are looking at a very rare condition. I am eagerly awaiting the results of the Royal College of Anaesthetists national audit regarding the incidence of epidural haematoma, but it would be interesting to know how other predisposing factors may have influenced the outcome. population. 2. Since it is a rare condition, and can present late, there should be a good element of suspicion for early diagnosis. Of particular concern is how little information GPs receive about the relevant aspect of anaesthetic compared to the information they get about their patient’s surgical procedure itself. I feel a patient who has had an epidural during their hospital stay should have a letter sent out to their GP warning about the red flag signs and symptoms of epidural abscess for early referral. References: 1. A R Mackenzie, R B S Laing et al, Spinal epidural abscess: the importance of early diagnosis and treatment: J Neurol, neurosurg, Psychiatry 1998:65:209-212 2. Baker A S, Ojemann et al, Spinal epidural abscess: NEJM: 293: 463- 8 3. Hlavin M L, Kaminsky K J et al, Spinal epidural abscess: a ten year perspective: Neurosurgery 1990;27:177-84 4. Danner R L, Hartman B J, Spinal epidural abscess - 35 cases and review of literature: Review of infectious diseases 1987; 9:265-74 5. Ericsson J, Algers G, Spinal epidural abscess in adults – Review of iatrogenic case: Scand J Infectious Deseases: 1990; 22: 249-57 6. Ozuna R M, Delamarter R B, Pyogenic vertebral osteomyelitis: Ortho clinics north America 1996; 27: 87-94 Conflict of Interest:None declared |
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James H Low, Consultant Intensive Care Medicine and Anaesthesia Derby Hospitals Foundation Trust
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Editor-I read with interest the recent editorial and accompanying article on haematomas and abscesses related to epidural analgesia 1. The authors of the editorial state that hospitals need to be able to MRI scan any patient who has unexplained neurology and an epidural in site within four hours of neurological symptoms starting. I would suggest that this would preclude most DGH hospitals from using epidural analgesia. Some still do not have an MRI scanner or if they do, do not offer a 24 hour service because of the technical support required. Organising a transfer within this time frame would be almost impossible. Looking at the situation from a slightly different angle I would say it must be almost impossible to consent patients for epidural analgesia. For example, Patient X is having a laparotomy. They do not have co existing respiratory disease and I propose to place an epidural for post operative analgesia. As an anaesthetist I should be saying to the patient that epidural analgesia has complications and that these can range from trivial to life threatening. Most patients would want to know about the life threatening complications. I will then have to say that we do not know the incidence of neurological complications (from whatever cause) but that we think it is a lot more common than was first believed. If I am working in an average UK hospital, I will then have to say that if a neurological complication occurs it is highly unlikely that we would not be able to investigate it in time to do anything about it! If patient X is still prepared to consider epidural analgesia they will then ask what the benefits are. I would have to say that if it works (and about 50% do not) it will give a 1cm improvement on a pain visual analogue score for the first two post operative days2. Would we honestly allow a new analgesic technique to be used so widely with this risk benefit profile? Undoubtedly a few patients benefit from epidural analgesia but we need to be a lot more selective in how it is used. The number needed to harm may be quite worrying when we eventually calculate it! James Low Derby, UK James.low@derbyhospitals.nhs.uk 1. Bedforth NM, A. R. Aitkenhead A.R., Hardman JG Haematoma and abscess after epidural analgesia.Br. J. Anaesth. 2008 101: 291-293. 2. Rigg JR, Jamrozik K, Myles PS, et al. MASTER Anaesthesia Trial Study Group. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82. Conflict of Interest:None declared |
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