Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review.

Background: Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation.

Methods: We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma.

Results: The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning.

Clinical relevance: pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility.

Conclusions: In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

Level of evidence: 3: