Dear Sir,
I read with interest Chung et al’s report of two patients who developed delayed post-operative spinal epidural haematoma after posterior spinal surgery. In both cases, magnetic resonance imaging (MRI) was utilised to accurately diagnose the haematoma compressing the spinal cord. They correctly emphasised the importance of having a high index of clinical suspicion and reported successful outcomes following surgical evacuation of haematoma1.
An alternative treatment to consider is imaging-guided percutaneous drainage of the intra-spinal haematoma. This can be achieved using an 18G Tuohy needle, ideally under computed tomography (CT) guidance2, although fluoroscopic guidance can also be utilised3. Besides epidural hematomas, CT-guided aspiration has also been advocated for decompression of epidural abscesses4.
The Tuohy needle is a widely-available standard needle used for epidural access by anaesthetists. This needle has a blunt rounded Huber tip that minimises the risk of damage to vital structures within the spinal canal. The curved tip also allows insertion of a plastic catheter that can be directed, hence enabling a more thorough aspiration of the intra-spinal haematoma beyond the point of the needle puncture site2.
Although open surgical drainage is the standard treatment of choice, CT-guided percutaneous drainage of acute or subacute intra-spinal haematoma may be an option where the patient is elderly and/or has high-risk comorbidities whereupon further open surgery and administrating general anaesthesia are not desirable. In the hands of a skilled proceduralist (e.g. musculoskeletal interventional radiologist), this minimally-invasive procedure can be quickly and accurately performed with low risk of trauma to the surrounding structures.
References
- 1.Chung WH, Tan RL, Chiu CK, Kwan MK, Chan CYW. Delayed post-operative spinal epidural haematoma after posterior spinal surgery: report of two cases. Malays Orthop J. 2020;14(3):170–3. doi: 10.5704/MOJ.2011.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Teo HEL, Peh WCG, Tan SB. Percutaneous drainage of a postoperative intraspinal hematoma using a Tuohy needle. Skeletal Radiol. 2003;32(10):603–7. doi: 10.1007/s00256-003-0666-5. [DOI] [PubMed] [Google Scholar]
- 3.Cha YD, Kim GW, Yang CW, Oh SR, Ryoo SW, Kim BG. Drainage of an acute spinal epidural hematoma that developed without risk factors in the thoracic spine using epidural needle - A case report. Anesth Pain Med. 2017;12(3):266–70. doi: 10.17085/apm.2017.12.3.266. [DOI] [Google Scholar]
- 4.Petrocheilou G, Vlachou I, Stathopoulou S, Kokkinis C. CT-guided percutaneous intraspinal needle aspiration for the diagnosis and treatment of epidural collections (abstract). ESSR. 2013:P-0064.. doi: 10.1594/essr2013/P-0064. [DOI] [Google Scholar]