Neuraxial anesthesia and analgesia (either by perioperative spinal or postoperative epidural catheter) has been shown to significantly improve pain control and other outcomes after major surgery as well as for trauma patients with multiple rib fractures. Simultaneously, data have shown lower rates of venous thromboembolic events in patients receiving chemical venous thromboembolic event prophylaxis with some form of anticoagulant (i.e., unfractionated or low-molecular-weight heparin [LMWH]). However, the concomitant use of anticoagulants and spinal or epidural anesthesia can result in the rare, but potentially devastating, spinal hematoma.

Patients with significant uncorrected bleeding disorders and those receiving anticoagulation are at significantly elevated risk of developing spinal hematoma in the setting of neuraxial anesthesia. The diagnosis of spinal hematoma is complicated by the concealed nature of the bleeding. A high index of suspicion must be maintained. Patients who have neurologic findings (e.g., weakness, decreased sensation, or incontinence) after undergoing a lumbar puncture or receiving spinal or epidural analgesia require emergent evaluation for possible spinal hematoma. Back pain is a common finding but is not present in all cases. Detailed physical examination should also include a rectal exam to evaluate tone. These physical examination findings should not be simply attributed to the epidural anesthetic. A computed tomography (CT) scan can often be obtained rapidly and may yield the diagnosis. However, magnetic resonance imaging (MRI) or myelography may be necessary for definitive diagnosis.