Rapid development of a spinal epidural hematoma following thoracic epidural catheter removal in an esophageal carcinoma surgical patient: a case report

Background: The occurrence of spinal epidural hematomas associated with the use of epidural catheters is relatively rare. Furthermore, it is unusual for hematoma-associated neurological symptoms to occur within 15 min of removing a catheter. Here, we report our experience with an esophageal carcinoma surgical patient who developed an epidural hematoma almost immediately after catheter removal, resulting in paralysis of his lower extremities. The patient achieved full neurological recovery following prompt diagnosis and surgical intervention.

Case presentation: A 68-year-old man was admitted with esophageal carcinoma and underwent video-assisted thoracoscopic esophagectomy followed by posterior mediastinal gastric tube reconstruction. During surgery, the patient was administered both general and epidural anesthesia. The epidural catheter was inserted approximately 5 cm into the epidural space at the Th6-7 level. The patient was extubated the following day in the general intensive care unit. Two days after surgery, the d-dimer level was high at 36.9 μg/mL (reference range 0-0.9 μg/mL), and we decided to administer an anticoagulant (enoxaparin sodium) to prevent thrombosis. The epidural catheter was removed 2 h prior to the scheduled administration of enoxaparin sodium. However, the patient reported a complete lack of strength in his lower extremities 15 min after catheter removal. Upon examination, the manual muscle testing score was 1 out of 5, and the patient experienced impaired touch sensation and cold sensation below Th4. An emergency magnetic resonance imaging scan was performed 2 h after catheter removal, which revealed a possible spinal epidural hematoma spreading from Th3 to Th6. Three hours after catheter removal, we began emergency surgery to evacuate the hematoma, which had spread to Th7. After surgery, the patient showed improvements in touch sensation, cold sensation, and motor function. The patient was able to walk 2 days after hematoma removal.

Conclusions: It is highly unusual for a spinal epidural hematoma to develop so rapidly after the removal of an epidural catheter. This case emphasizes the need for vigilant patient monitoring, rapid diagnosis, and prompt surgery to ensure adequate neurological recovery in these patients.