You are considering placing an epidural in your patient whose platelet count is 76,000 × 106/L. According to a recent meta-analysis, which of the following is MOST likely true regarding the complication of spinal epidural hematoma after lumbar neuraxial procedures in thrombocytopenic patients?

  • □ (A) More than 100 cases of spinal epidural hematoma were reported from 1947 to 2018.

  • □ (B) Spinal epidural hematoma was rare in obstetric patients.

  • □ (C) Spinal epidural hematoma was most commonly seen after a combined spinal-epidural procedure.

The decision of whether to perform a neuraxial anesthetic procedure in a thrombocytopenic patient has serious implications. Avoiding regional anesthesia can result in decreased postoperative analgesia, with increased opioid requirements leading to increased occurrence of ileus, pruritus, urinary retention, and nausea/vomiting. In the obstetric population, performing general anesthesia instead of neuraxial anesthesia increases the risk of failed maternal intubation, poor postoperative analgesia, and increased risk of fetal exposure to anesthetic agents. However, the risks associated with performing neuraxial procedures in thrombocytopenic patients cannot be overlooked. The development of a spinal epidural hematoma after a neuraxial procedure in a thrombocytopenic patient can result in severe weakness, radicular back pain, bowel and bladder incontinence, cauda equina syndrome, and paraplegia or quadriplegia. Because spinal epidural hematoma case reports are rare, more data are needed to adequately weigh the risks and benefits of neuraxial procedures in thrombocytopenic patients. Further, there is currently little agreement among anesthesia providers regarding the minimum platelet count in thrombocytopenic patients to ensure the safe delivery of neuraxial procedures.

To better elucidate the risk of spinal epidural hematoma after lumbar neuraxial procedures in thrombocytopenic patients, a recent systematic review and meta-analysis examined 131 articles with a total of 7,509 lumbar neuraxial procedures performed in adults and children between 1947 and 2018. Lumbar neuraxial procedures were defined as lumbar puncture, spinal, epidural, combined spinal-epidural, or epidural catheter removal. Thrombocytopenia was defined as a platelet count less than 100,000 × 106/L. Of the 7,509 procedures performed in thrombocytopenic patients, there were 5,083 lumbar punctures, 981 epidurals and combined spinal-epidurals, 895 unspecified neuraxial procedures, 531 spinals, and 19 epidural catheter removals. There were 33 spinal epidural hematomas, of which 25 occurred following lumbar puncture (75.8%); six following spinals (18.2%); one following epidural catheter placement (3%); and one following epidural catheter removal (3%). The platelet count ranges for these 33 spinal epidural hematomas were 1-25,000 × 106/L (14 cases), 26,000-50,000 × 106/L (six cases), 51,000-75,000 × 106/L (nine cases), and 76,000-99,000 × 106/L (four cases). This being a truly observational study, the authors were unable to adjust for factors that may have contributed to an increased risk of bleeding.

The review was not able to document specific predictors indicative of an increased risk for spinal epidural hematoma; however, key observations were made to help guide the practice of lumbar neuraxial procedures in thrombocytopenic patients. Although there is evidence that suggests pediatric patients are at higher risk of bleeding than adult patients, this was not observed in the sample of this comprehensive study. Clinical or laboratory evaluation for adequate hemostasis, as well as platelet function, is recommended in thrombocytopenic patients prior to lumbar neuraxial procedures. Large epidemiological studies have shown that obstetric patients, who are known to be hypercoagulable and receive neuraxial anesthesia far more often than other patient populations, are at lower risk for spinal epidural hematoma than the general population. In this review, there were only five obstetric cases of reported spinal epidural hematomas, with a platelet count ranging from 44,000 to 91,000 × 106/L. Of the five cases, one had an arteriovenous malformation, one was coagulopathic, two had HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, and one had eclampsia, all in addition to thrombocytopenia.

In conclusion, spinal epidural hematoma in thrombocytopenic patients after neuraxial anesthesia is rare. A low spinal epidural hematoma event rate (0.097%) was found in patients with a platelet count of 75,000 × 106/L or above. Patient education regarding symptoms of spinal epidural hematoma is very important when performing neuraxial anesthesia in patients with thrombocytopenia.

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et al
Lumbar neuraxial procedures in thrombocytopenic patients across populations: a systematic review and meta-analysis
J Clin Anesth
. doi:10.1016/j.jclinane.2019.109666

Answer: B