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| Year : 1999 | Volume
: 47
| Issue : 4 | Page : 339-40 |
Spinal subarachnoid haematoma following lumbar puncture.
Goyal A, Dua R, Singh D, Kumar S
How to cite this article:
Goyal A, Dua R, Singh D, Kumar S. Spinal subarachnoid haematoma following lumbar puncture. Neurol India 1999;47:339 |
Haemorrhage into the spinal canal can be a complication of lumbar puncture.[1] Reported haematomas in the spinal canal are commonly epidural.[2] Subarachnoid haematoma following lumbar puncture is exceedingly rare, even in patients with bleeding disorders.[3-6] Very rarely a clot may form in the subarachnoid space and if sufficiently large, may compress the spinal cord or cauda equina producing progressive neurological deficit. A case of cauda equina compression caused by subarachnoid haematoma following lumbar puncture is being reported because of its rarity.
A 25 years female had lower segment cessarean section (LSCS) in Oct.97 elsewhere. For the surgical procedure spinal anaesthesia was attempted, but because of failure to obtain cerebrospinal fluid, no anaesthetic agent was given intraspinally and operation was completed under general anaesthesia uneventfully. Three days following LSCS, patient developed sudden onset pain in right lower limb followed by weakness and numbness in right lower limb. There was no bladder, bowel involvement. On examination higher mental functions and upper limbs were normal. Patient had flaccid paraparesis. The power at right hip and knee joint was 3/5 and at ankle was 0/5. The power on left side was 4/5 in all muscle groups. [Right] sided knee and ankle jerks were absent. Plantars were mute. There was 75-100% sensory loss, to all modalities, in L4-S1 dermatomes. All routine investigations including coagulation profile were within normal limits. MRI revealed a well defined oval 1.5x1.1 cm. size intradural extramedullary mass at L3 level on right side. It showed heterogenous hyperintense signal on T1 and heterogenous mildly hyperintense signal on T2 weighted images [Figure. 1]. At laminectomy dura was tense, bluish and nonpulsatile. On opening the arachnoid a solid dark liquified haematorna was found, surrounded by roots of cauda equina. Haematoma was evacuated. Sensory recovery occurred within few days after surgery. Power in the lower limbs gradually improved to grade V with in few months.
A traumatic tap resulting in blood stained CSF fluid is most often due to puncture of the dorsal or ventral epidural venous plexuses, and is usually without any consequences. Eldelson et al[3] suggested that subarachnoid haematoma occurs when radicular vessels are lacerated by traumatic lumbar puncture. Masdeu et al[6] have confirmed this mechanism at autopsy. Blood in the subarachnoid space usually does not clot, probably because of the great dilution by spinal fluid. Defibrination of blood from the pulsatile motion derived from the brain and spinal cord may be an additional factor. Subarachnoid haematoma is probably not produced when the bleeding from a radicular vessel is trival. Conversely, if the bleeding is massive or rapid, clotting does indeed occur. Lethargy, headache and meningeal signs may follow bleeding in the spinal subarachnoid space. Most cases of spinal subarachnoid haematoma probably follow this benign course or pass unnoticed. However, when the collection of blood is large, there may be local pain, flaccid paraparesis, impairment of sensation in the lower limbs and sphincter disturbances.[1],[2] In this setting, prompt evacuation of the haematoma is mandatory to prevent a permanent neurological deficit.
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| 3. | Edelson RN, Chernik NL, Posner JB : Spinal subdural haematomas complicating lumbar puncture. Occurrence in thrombocytopenic patients. Arch Neurol 1974; 31 : 134-137. |
| 4. | King OJ, Glas WW : Spinal subarachnoid haemorrhage following lumbar puncture. Arch Surg 1960; 80 : 574-577. |
| 5. | Kirkpatrick D, Goodman SJ : Combined subarachnoid and subdural spinal haematoma following spinal puncture. Surg Neurol 1975; 3 : 109-111. |
| 6. | Masdeu JC, Breuer AC, Schoene WC : Spinal subarachnoid haematomas : clue to a source of bleeding in traumatic lumbar puncture. Neurology 1979; 29 : 872-876. |
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