DP16: THE DOWNSIDE OF DRAINING: A CASE OF POST REMOVAL SPINAL HEMATOMA
Meena Kanhai, MD; Kevin Priddy, MD; Alessandra Costello-Serrano, MD; Natalie Lowe, MD; Erika Taco-Vasquez, MD
University of Florida
Introduction: Spinal drains are lumbar cerebrospinal fluid drains that are utilized in repair of aortic aneurysms to help prevent and manage spinal cord ischemia. We present a 73 year old female with history of coronary artery disease, status post cardiac stent placement on aspirin, and atrial fibrillation on warfarin who developed a spinal hematoma after the removal of a spinal drain placed for complex abdominal aortic aneurysm repair via physician modified endovascular grafts (PMEG) despite following ASRA coagulation guidelines. We discuss reconsidering when to place spinal drains in high-risk patients.
Materials and Methods: As the case report is devoid of patient identifiable information, it is exempt from IRB review requirements as per University of Florida policy.
Results/Case Report: A 73-year-old female, BMI 20.4 kg/m2, presented for complex abdominal aortic aneurysm repair. Her past medical history included: hypertension, hyperlipidemia, atrial fibrillation on warfarin, chronic obstructive pulmonary disorder, cigarette smoking, coronary artery disease s/p coronary stent on aspirin, and type 2 diabetes mellitus. At the request of the surgical team, a spinal drain was placed preoperatively without reported complications. Warfarin was stopped for 7 days and ASA 81 mg for 5 days with day of surgery INR 1.1 and platelets 189 prior to placement.
She underwent four-vessel PMEG with SMA, bilateral renal, and iliac stents. Intraoperatively, she received a total of 4000 units of heparin (final ACT 164, baseline 148), which was reversed with 50 mg of protamine. A total of 38 mL of CSF was drained during the procedure. Upon ICU admission, she was considered as high risk for spinal cord ischemia and managed with MAP goals > 80 mmHg on norepinephrine infusion and spinal drain set to drain at 10 cmH20. She reminded neurologically intact.
On POD1, the drain creased functioning, likely due to a kink, and was clamped. On POD2, it was removed. Eight hours later, she developed acute, intense back pain without neurological deficits. MRI revelated lumbar subarachnoid hematomas, which neurosurgery deemed nonoperative. Pain was managed with ketamine infusion and multimodal analgesia.
On POD 3, she developed new onset left lower extremity weakness. Repeat MRI showed expanding intrathecal hematoma (from 4.7 cm to 6.0 cm), continued to be nonoperative. Following treatment with methylprednisolone and mannitol, her neurological deficits improved. Later in her hospital stay, she suffered a STEMI with subsequent Takotsubo’s cardiomyopathy and was later readmitted after a fall secondary to her lower extremity weakness.
Discussion: Spinal drains are crucial for preventing spinal cord ischemia by enhancing spinal cord perfusion pressure through CSF drainage and increased arterial pressure. Prophylactic drains in thoracic endovascular aortic repair reduce spinal cord injury incidence to 1.3%. However, the risk of spinal hematoma post-drain placement ranges from 3.9% to 27%, dependent on atraumatic placement and coagulation status. Despite following risk-mitigation guidelines, a postoperative hematoma occurred in this patient followed by multiple complications. This raises questions about the favorable initial risk-to-benefit ratio with drainage duration under 48 hours and highlights the necessity of careful selection of these patients for perioperative spinal drain placement.