Influence of antithrombotic medication on size and neurological outcome of spinal epidural hematoma after neuraxial anesthesia: a systematic review

Abstract

Introduction Anticoagulation guidelines were developed to reduce the potential risk of epidural bleeding following neuraxial anesthesia. However, the influence of antithrombotic medication on size of spinal epidural hematoma and neurological outcome is unclear. Therefore, our aim was to analyze whether there is a correlation. Methods The study was registered at Prospero (CRD42021285833). A systematic search in MEDLINE, EMBASE, CENTRAL, Web of Science and Google Scholar was conducted in August 2023 for studies reporting spinal epidural hematoma following neuraxial anesthesia. Primary endpoints were segmental extension and neurological outcome. Secondary endpoints were age, sex, body mass index, predisposition, American Society of Anesthesiologists physical status, complicated puncture, multiple punctures, bloody puncture, successful puncture, catheter usage, needle size and worst neurological deficit before treatment. Prespecified multivariate regression and propensity score matching was performed. Publications reporting on more than one patient were critically appraised. Results A total of 345 cases reported in 304 publications were included. Size of hematoma was not significantly different (antithrombotic medication: OR 0.11, 95% CI (−0.67 to 0.89), p=0.78, ‘non-guideline adherent’ for puncture/removal: OR 0.13, 95% CI (−0.92 to 1.18), p=0.81). Patients receiving antithrombotic medication were more likely to have persistent neurological deficit (OR 2.00, 95% CI 1.24 to 3.23), p<0.01). Significance persisted after propensity score matching (p=0.04). Patients with non-guideline adherence had a 3.42 higher chance of persistent neurological deficit (95% CI 1.71 to 6.86, p<0.001). Discussion Antithrombotic medication is not significantly associated with hematoma size; however, the use of antithrombotic medication doubled the risk for persistent neurological deficit after spinal epidural hematoma. All data relevant to the study are included in the article or uploaded as online supplemental information.