• This Guideline aims to provide guidance on the recognition and management of suspected vertebral canal haematoma for anaesthetic, midwifery and obstetric staff.
• Vertebral canal haematoma (VCH) is a rare complication of central neuraxial (epidural and spinal) block.
• VCH if untreated may result in permanent, devastating nerve damage.
• VCH should be suspected in the event of delayed or incomplete return of motor or sensory function following central neuraxial block or an excessively dense block during epidural analgesia.
• Consultant-to-consultant referral to radiology for urgent MRI scan is necessary if VCH is thought to be possible.

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Abbreviations

Vertebral canal haematoma (VCH) is a rare complication of central neuraxial (epidural and spinal) block. The Royal College of Anaesthetists’ third National Audit Project (NAP3 audit) sought to quantify serious outcomes from central neuraxial block. No cases of VCH were reported following more than 300 000 central neuraxial blocks in obstetric patients, and there were no cases of VCH consequent to greater than 360 000 obstetric and non-obstetric spinals.¹ There were six cases of confirmed VCH in the time frame of the study, all involving epidural procedures for perioperative pain relief in non-obstetric patients. However, the outcome from this rare event is often devastating, permanent neurological injury.

Risk Factors for Developing Vertebral Canal Haematoma

The NAP3 audit demonstrated a reduced incidence of VCH in obstetric compared to non-obstetric patients, an observation that is borne out in other case series.² Coagulopathy, whether drug induced or due to patient co-morbidities, is a very important risk factor^{1 3} and guidelines regarding neuraxial blocks in patients receiving low molecular weight heparin (LMWH), affected by thrombocytopaenia, or suffering from pre-eclampsia with associated coagulopathy, should be consulted. Spinal deformity, vessel fragility or abnormality, and repeated attempts at neuraxial block are also associated with increased risk.³

Presentation of Vertebral Canal Haematoma

VCH should be suspected in the event of delayed or incomplete return of motor or sensory function following central neuraxial block, or excessive motor block during epidural analgesia. The diagnosis should still be considered in the event of unilateral signs. Associated back pain is an inconsistent finding.¹

Identification of Obstetric Patients with Suspected Vertebral Canal Haematoma

All obstetric patients receiving neuraxial blocks should be monitored for the possibility of VCH.⁴

Excessively dense motor block (inability to straight leg raise from the bed, even if only unilateral) while having epidural analgesia should prompt the midwife to contact the duty anaesthetist for assessment. The midwife should undertake motor assessment of the block in line with the regular assessments of sensory block.⁴

All women should have an assessment by midwifery staff of ability to straight leg raise 4 hours after removal of an epidural catheter or 4 hours after a spinal anaesthetic.⁴ If bilateral leg movement is NOT normal then the obstetric anaesthetist (FPH bleep 5112, WPH bleep 4490) should be contacted urgently to assess the patient.

Management of Obstetric Patients with Suspected Vertebral Canal Haematoma

In the event of persistent motor deficit 4 hours following epidural catheter removal or spinal insertion, the duty obstetric anaesthetist should contact the consultant anaesthetist on duty for obstetrics (FPH bleep 5591 or WPH via mobile phone) or the on-call consultant if out-of-hours. They should also ensure that no further anticoagulant medications are administered until further investigation has taken place. Consultant-to-consultant referral to radiology for urgent MRI scan is necessary if VCH is thought to be possible. In the event of an intradural or extradural problem being identified on imaging, the consultant anaesthetist should make urgent contact with a neurosurgical centre (the John Radcliffe, Oxford, for WPH or St George’s Hospital, London, for FPH). Spinal surgeons operate electively at Frimley Park Hospital but do not offer an emergency service. They may be consulted for advice regarding an extradural haematoma, if time of day is appropriate, but there should be no delay to communication with a neurosurgical centre. Neurological recovery is proportional to time taken until decompression of vertebral canal haematoma; decompression should take place within 8-12 hours to maximise chances of good neurological recovery^{3, 4}.

• This guideline will be discussed at both anaesthetic departmental meetings and the labour ward forums.

• If there are communication issues (e.g., English as a second language, learning difficulties, blindness/partial sightedness, deafness) staff must take appropriate measures to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them. Communication difficulties are recognised as a risk of delayed diagnosis of VCH and so it is imperative that whatever necessary steps are taken to facilitate effective communication.

• This guideline will be subject to monitoring by the anaesthetic department.

1. Royal College of Anaesthetists. The Third National Audit Project of The Royal College of Anaesthetists (NAP3) Major Complications of Central Neuraxial Block in the United Kingdom. Royal College of Anaesthetists: London; 2009 Available from: https://www.nationalauditprojects.org.uk/NAP3_home

2. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101(4): 950-9 Available from: https://pubs.asahq.org/anesthesiology/article/101/4/950/6560/Severe-Neurological-Complications-after-Central

3. Yentis S, Lucas D, Brigante L. Safety guideline: neurological monitoring associated with obstetric neuraxial block. Anaesthesia. 2020; 75: 913-919.

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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