A patient receives epidural analgesia via an L2–3 catheter and 2 hours later develops sudden severe back pain, bilateral leg weakness, bladder dysfunction and saddle anaesthesia. The MOST urgent diagnosis to exclude and the action required is:

• A Postdural puncture headache — treat conservatively with bed rest and fluids
• B Local anaesthetic toxicity — IVLE (Intralipid) therapy and call cardiac arrest team
• C Cauda equina syndrome from disc prolapse — semi-elective MRI within 24 hours
• D Epidural haematoma — urgent MRI spine and neurosurgical decompression within 6–8 hours of symptom onset ✓

Explanation

Epidural haematoma is a rare but catastrophic complication of neuraxial anaesthesia, causing rapid onset spinal cord compression. The classic presentation is new or worsening back pain with progressive neurological deficit (motor weakness, sensory loss, bladder/bowel dysfunction). Prognosis is directly related to time to decompression: neurological recovery is excellent if surgery is performed within 6–8 hours but poor if delayed >12 hours. Immediate MRI (CT if MRI unavailable) and urgent neurosurgical consultation are mandatory. This also applies to epidural abscess (which has a more subacute onset with fever). Postdural puncture headache is positional and without motor/bladder deficits.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.