subdural spinal hematoma is an extremely rare complication of spinal and epidural anesthesia and may lead to cauda equina syndrome , bowel bladder dysfunction or even complete permanent paraplegia .
a 60-year - old female patient was diagnosed to have osteoarthritis of right knee joint and was advised knee arthroplasty .
enoxaparin sodium 40 mg ( lmwh ) was started 9 h after surgery and was followed by once daily dose .
foot pump and compression stockings were applied for deep vein thrombosis ( dvt ) prophylaxis . on day 2 , the epidural catheter was removed 13 h after last dose , and she was discharged on 3 postoperative day in stable condition . at the time of discharge ,
on 4 postoperative day , she developed sudden onset pain in the lower back which was radiating to left lower limb .
the pain was followed by loss of sensation and weakness in the left lower limb .
it showed a large subdural hematoma , which was compressing the thecal sac at l2-l3 level .
laminectomy with decompression of spinal cord and evacuation of hematoma was done on the emergent basis .
postoperatively patient recovered well with complete control over bowel and bladder functions , but foot drop on the left side persisted after 6 months of follow - up .
combined spinal epidural anesthesia though safe has been associated with uncommon neurologic complications like subdural hematoma .
venous stasis , endothelial injury and hypercoagulable conditions contribute to the postoperative development of dvt which can be a life - threatening complication . in surgeries as total knee and hip replacement , direct injury to the large vessels of lower limb predispose patients for increased chances of dvt especially in absence of postoperative anticoagulation prophylaxis .
however , prophylaxis must be balanced against the risks for postoperative bleeding and epidural hematoma .
spinal and epidural anesthetic procedures in combination with anti - coagulant therapy represent the fifth most common cause of spinal hematoma .
three cases developed paraplegia due to subdural hematoma which was due to underlying coagulation disorder .
and horlocker and wedel highlighted the risk of spinal hematoma which gets aggravated by concomitant administration of anticoagulants and anti - platelet drugs .
fryburg et al . , reported two patients who suffered from spontaneous acute spontaneous subdural hematoma while taking fondaparinux for venous thromboembolism prophylaxis .
it is recommended that lmwh should be used once daily and to be started 12 - 24 h postoperatively , especially when indwelling spinal catheter are present or when concomitant antiplatelet or oral anticoagulant medication is being given .
patients who develop extra or subdural hematoma usually present with acute back or radicular pain radiating to limbs , followed by progressive sensory and motor involvement in either one or both the lower limbs along with saddle anesthesia and bowel and bladder dysfunction . in most of the cases , these symptoms usually develop shortly after the procedure with mean age of onset being 30 h after operation , but in our case , the patient developed sudden onset neurological symptoms suggestive of cauda equina syndrome on 4 postoperative day .
urgent mri was done to confirm the diagnosis and patient was immediately taken to the operation theatre where laminectomy with decompression of spinal canal and evacuation of hematoma was done .
, neurosurgical intervention must be sought immediately , because recovery is unlikely if surgery is postponed for more than 8 h. this case highlights that even in the absence of an existing spinal pathology and carefully administrated spinal - epidural anesthesia , cse may cause dreaded neurologic complication like subdural hematoma especially in the presence of anti - coagulant therapy .
hence frequent 4 hourly neurological examination is essential for early detection of hematoma , which should be continued 24 hours postoperatively following a neuraxial block or upto 24 hours following catheter removal if patient is anticoagulated . in a case of suspected cauda equina syndrome
, the patient should be investigated and urgent decompression should be done on emergent basis to prevent permanent neurological sequelae .
 combined spinal - epidural anesthesia ( cse ) is considered safe in lower limb surgeries . 
 we report a case of sudden neurological deterioration in a stable postoperative patient who was given cse for total knee replacement and low molecular weight heparin in postoperative period . on the 4th postoperative day 
 , she developed sudden onset weakness in left lower limb along with bladder incontinence . 
 magnetic resonance imaging spine revealed a subdural hematoma at l2-l3 level . 
 immediate laminectomy along with cord decompression was done and patient recovered well except for a persistent foot drop on left side . 
Introduction
Case Report
Discussion