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Epidural Haematoma Post-LMWH — FRCA Final MCQ

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HardRegional AnaesthesiaEpidural Haematoma Post-LMWHFRCA Final

A 72-year-old man (ASA III) undergoes an open AAA repair under GA with a thoracic epidural. At 10 hours post-operatively he develops bilateral leg weakness (MRC 2/5), urinary retention, and loss of sensation below the umbilicus. His epidural was removed 3 hours ago and he received a dose of LMWH enoxaparin 40 mg 2 hours before epidural removal. What is the most urgent investigation and why?

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Correct answer: B — CT angiogram – aortic graft occlusion

The combination of bilateral leg weakness, urinary retention, and sensory level following epidural removal in a patient who received LMWH within 2 hours of catheter removal is HIGHLY SUSPICIOUS for epidural haematoma. This is a neurosurgical EMERGENCY. MRI of the whole spine is the investigation of choice – it must be obtained URGENTLY (within 1 hour). Surgical decompressive laminectomy within 6-12 hours of symptom onset gives the best chance of neurological recovery. The LMWH timing violates guidelines (minimum 4 hours after catheter removal), highlighting the importance of strict adherence to anticoagulation timing around neuraxial procedures.

Reference: Association of Anaesthetists – 2013 – Regional anaesthesia and coagulation; RCOA/AAGBI – 2021 – NAP3/NAP4