To the Editor:—
I wish to comment on the case report by Maier et al. about severe hematomas after lumbar sympathetic blockades in patients under irreversible platelet inhibitors. 1I would like to highlight, respectfully, that inappropriate MEDLINE searches were performed. The authors stated, “There are no studies regarding the safety of epidural or spinal anesthesia in patients during or immediately after discontinuation of antiplatelet drug treatment. Only one case report describes a subarachnoidal hematoma following a very difficult lumbar puncture in a patient receiving ticlopidine.” Horlocker et al. 2prospectively studied 1,000 procedures in 924 patients given spinal or epidural anesthesia to determine whether preoperative antiplatelet medications were related to the development of hemorrhagic complications. Antiplatelet therapy was defined as aspirin or any other nonsteroidal antiinflammatory drug. There were no documented spinal hematomas. A literature search on the National Library of Medicine's MEDLINE system identified three reports of spinal hematoma associated with ticlopidine therapy and central block. 3–5Mayumi and Dohi 3described a case of a 70-yr-old woman admitted for amputation of the first toe during spinal anesthesia. Ticlopidine administration was discontinued. After several unsuccessful attempts at lumbar puncture using a 23-gauge spinal needle, the operation was performed during general anesthesia. On the second operative day, urinary retention developed. Six days after surgery, muscle weakness developed and on the eighth postoperative day, a myelogram demonstrated an extramedullary hematoma. At laminectomy, a hematoma was found in the subarachnoid space. The neurosurgeon noted no vascular abnormalities or tumors. This was the first spinal hematoma reported in association with central nervous block in a patient without a vascular tumor who was taking ticlopidine. Kawaguchi and Tokutomi 4described a 72-yr-old woman admitted for choledocholithotomy during general anesthesia combined with epidural block. Ticlopidine administration was stopped 12 days before the operation. An epidural catheter was inserted at T9–10 interspace. Just after the operation, motor paralysis occurred. After 2 days, magnetic resonance imaging revealed epidural hematoma extending from T7 to L1.
