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Fulltext Pneumocephalus Following Combined Spinal Epidural Anaesthesia for Total Knee Arthroplasty: A Case Report

Chew YW, Suppan VK, Ashutosh SR, Tew MM, Jimmy-Tan JH

Malays Orthop J, 2017 Nov;11(3):42-44.
PMID: 29326765 MyJurnal DOI: 10.5704/MOJ.1711.001

The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.

Matched MeSH terms: Epidural Space
Fulltext Bilateral epidural extension of thoracic capillary vertebral (intraosseous) hemangioma mimicking spinal meningioma

Kan CH, Saw CB, Rozaini R, Fauziah K, Ng CM, Saffari MH

Med J Malaysia, 2008 Jun;63(2):154-6.
PMID: 18942307 MyJurnal

We describe a rare case of vertebra (intraosseous) hemangioma with bilateral and symmetrical epidural extension causing cord compression in a 24-year-old woman. The epidural component was isointense to cord on both T1 and T2 sequences, and enhanced markedly and homogenously following gadolinium administration. The gradual in onset and progressive nature with the typical enhancing pattern lead the neurosurgeon to the more common diagnosis of spinal meningioma. Epidural extension of vertebral hemangiomas causing cord compression is rarely reported. Review of literatures reveal that cases that have been reported are of unilateral extension into epidural space and of cavernous type. This is the first case report of capillary vertebral (intraossous) hemangioma with bilateral extension through both intervetebral foramen into the epidural space causing myelopathy.

Matched MeSH terms: Epidural Space/pathology*
Fulltext Unusual Posterior Epidural Migration of Intervertebral Herniated Disc: A Report of Two Cases

Tamburrelli FC, Perna A, Oliva MS, Giannelli I, Genitiempo M

Malays Orthop J, 2018 Nov;12(3):47-49.
PMID: 30555647 DOI: 10.5704/MOJ.1811.012

Disc herniation is one of most common causes of spine surgery. Because of the presence of posterior longitudinal ligaments, disc fragments often migrate into the ventral epidural space. A posterior epidural herniation of a disc fragment is a rare occurrence. We report two cases of posterior migrated disc fragments, with, radiological and clinical findings. Because of the rarity of a posterior migration of the intervertebral disc fragments, a differential diagnosis can be challenging. This painful syndrome associated with neurological lower limb deficits can be confused initially, with other posterior epidural space-occupying lesions such as tumours, abscess or hematomas. A gadolinium-enhanced MRI scan is the gold standard for a correct diagnosis. Early surgical decompression of the spine with a posterior approach remains the optimal technique in ensuring the best possible outcome for the patient.

Matched MeSH terms: Epidural Space
Epidemiology, spectrum of clinical manifestations and diagnostic issue of acquired haemophilia: A case series

Wan Ab Rahman WS, Abdullah WZ, Husin A, Nik Mohd Hassan NFF, Hassan MN, Zulkafli Z

Malays J Pathol, 2019 Aug;41(2):185-189.
PMID: 31427554

INTRODUCTION: Acquired haemophilia A (AHA) is a rare acquired bleeding disorder caused by polyclonal immunoglobulin G autoantibodies against clotting factor VIII (FVIII). The incidence was reported to be rare occurring in 0.2- 4 cases/million/year. Patients may present with different clinical manifestations to various specialties. Early recognition of the disease contributes to favourable clinical outcome.
CASE SERIES: Here, we reported five cases of this disorder with different clinical presentations from two tertiary hospitals in Kelantan state, Malaysia within a two year-period. Most of them were elderly, except for one who presented at the age of 36 years old. No direct or secondary cause was identified except for one patient who had developed from pregnancy-related at 3 weeks postpartum. These patients presented with spontaneous bleeding typically into skin, muscles, and mucous membranes but also at rare site in the epidural space. All patients denied previous history of bleeding or family history of bleeding disorder. FVIII activities were recorded between <1% to 19%, while the inhibitor titre levels were between 3.9 BU to 340 BU. The treatment approaches especially at presentation were complicated by unfamiliarity of managing this rare condition but all these patients received appropriate medical attention.
DISCUSSION: Prompt diagnosis and management in the right hand are critical. Awareness of this disorder by medical personnel at all levels in the community and in various specialties is important.

Matched MeSH terms: Epidural Space
Fulltext Spontaneous Spinal Epidural Hematoma Associated With the Use of Low-dose Aspirin in Elderly Patient

Phang ZH, Chew JJ, A/P Thurairajasingam J, Ibrahim SB

J Am Acad Orthop Surg Glob Res Rev, 2018 Oct;2(10):e059.
PMID: 30656250 DOI: 10.5435/JAAOSGlobal-D-18-00059

Spontaneous spinal epidural hematoma is a rare condition defined by bleeding in the epidural space of the spine with no identifiable causes such as trauma, vascular malformation, or bleeding disorders. This is a case of a 79-year-old woman with a medical history of diabetes mellitus, dyslipidemia, and hypertension presented with the sudden onset of severe thoracolumbar back pain associated with weakness and numbness in her bilateral lower limb. Examination of the lower limb showed bilateral lower limb motor and sensory deficits. Laboratory investigations showed normal results. MRI showed posterior extradural intraspinal hematoma from T11 to L3 vertebrae. Patient underwent right hemilaminectomy and posterior decompression of T12 and L1 vertebrae to evacuate the hematoma. Postoperatively, her neurologic complications improved gradually. Decision was made not to restart aspirin. On follow-up at 1 year, the patient had complete recovery of neurologic complications of both lower limb and had no recurrence of bleeding. In short, this is a case of spontaneous spinal epidural hematoma associated with long-term use of low-dose aspirin in an elderly patient requiring surgical evacuation of hematoma with good functional outcome after the surgery. Therefore, aspirin should be prescribed cautiously especially to elderly patients.

Matched MeSH terms: Epidural Space
Fulltext Streptokinase after Spinal Anaesthesia – A Case Report

Hadi, M.R.A., Basri, M.N., Ariff, O.

International Medical Journal Malaysia, 2006;5(1):1-4.
MyJurnal

The use of thrombolytic agent e.g. streptokinase is indicated in patients with early acute ST elevation myocardial infarction (MI) (if there are no contraindications) is becoming increasingly routine. Its use is however significantly limited by bleeding complications. Spinal epidural haematoma (SEH) is haemorrhage in the spinal epidural space after spinal anaesthesia. SEH may be acute or chronic, spontaneous, posttraumatic, or iatrogenic but its occurrence appears to be particularly associated with acquired coagulopathy from medications and disease states. Patients usually present with acute axial spine pain and evolving focal neurological deficits. With increasing number of available anticoagulants and patient receiving them, anaesthesiologists today have to face the challenge of balancing between risks and benefits of regional anesthesia in patients under such medications. The treatment of this condition involves the principles of conservative follow-up directed by an improving examination and an understanding of the pathophysiology of coagulopathy-induced spontaneous epidural bleeds. When the diagnosis is accomplished rapidly, surgical decompression can result in full functional recovery.

Matched MeSH terms: Epidural Space
Symptomatic spinal epidural lipomatosis after a single local epidural steroid injection

Tok CH, Kaur S, Gangi A

Cardiovasc Intervent Radiol, 2011 Feb;34 Suppl 2:S250-5.
PMID: 20859631 DOI: 10.1007/s00270-010-9982-z

Spinal epidural lipomatosis is a rare disorder that can manifest with progressive neurological deficits. It is characterized by abnormal accumulation of unencapsulated epidural fat commonly associated with the administration of exogenous steroids associated with a variety of systemic diseases, endocrinopathies, and Cushing syndrome (Fogel et al. Spine J 5:202-211, 2005). Occasionally, spinal epidural lipomatosis may occur in patients not exposed to steroids or in patients with endocrinopathies, primarily in obese individuals (Fogel et al. Spine J 5:202-211, 2005). However, spinal lumbar epidural lipomatosis resulting from local steroid injection has rarely been reported. We report the case of a 45-year-old diabetic man with claudication that was probably due to symptomatic lumbar spinal lipomatosis resulting from a single local epidural steroid injection.

Matched MeSH terms: Epidural Space*
Fulltext A Good Short-term Outcome in Delayed Decompression of Cauda Equina Syndrome in Klebsiella pneumoniae Spinal Epidural Abscess: A Case Report

Hanifah J, Joehaimey J, Yusof MI

Malays Orthop J, 2017 Jul;11(2):85-88.
PMID: 29021888 MyJurnal DOI: 10.5704/MOJ.1707.018

Spinal epidural abscess is a severe, generally pyogenic, infection of the epidural space of spinal cord or cauda equina. The swelling caused by the abscess leads to compression or vascular disruption of neurological structures that requires urgent surgical decompression to avoid significant permanent disability. We share a rare case of Klebsiella pneumoniae spinal epidural abscess secondary to haematogenous spread of previous lung infection that presented late at our centre with cauda equina syndrome that showed good short-term outcome in delayed decompression. A 50-year old female presented with one-week history of persistent low back pain with progressively worsening bilateral lower limb weakness for seven days and urinary retention associated with saddle anesthesia of 2-day duration. Magnetic resonance imaging with contrast of the lumbo-sacral region showed an intramuscular collection of abscess at left gluteus maximus and left multifidus muscle with a L3-L5 posteriorly placed extradural lesion enhancing peripherally on contrast, suggestive of epidural abscess that compressed the cauda equina. The pus was drained using the posterior lumbar approach. Tissue and pus culture revealed Klebsiella pneumoniae, suggestive of bacterial infection. The patient made immediate improvement of muscle power over bilateral lower limbs postoperative followed by ability to control micturition and defecation the 4th post-operative day. A good short-term outcome in delayed decompression of cauda equine syndrome is extremely rare. Aggressive surgical decompression combined with antibiotic therapy led to good short-term outcome in this patient despite delayed decompression of more than 48 hours.

Matched MeSH terms: Epidural Space