Phoenix—The devastating neurologic complications that sometimes accompany epidural hematoma may be a thing of the past at Vanderbilt University Medical Center in Nashville, Tenn. Clinicians at the institution have implemented an expedited protocol for magnetic resonance imaging that involves several different medical specialties and significantly decreases the time from detection of neurologic symptoms to diagnosis.

Rajnish K. Gupta, MD, assistant professor of anesthesiology at the institution, described the case of a woman receiving an epidural who began to display signs of neurologic deficit, but for a variety of reasons experienced a series of delays lasting almost 10 hours. “She eventually got to the operating room, but was unfortunately paralyzed with an epidural hematoma,” he said. “This is a case in which I was personally involved, and it made me realize that rare events often require system changes. So, we tried to change the system—not just the personnel.” Dr. Gupta presented the case study at the 2009 annual spring meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract A47).

MRI scans are a critical element in making a proper diagnosis of epidural hematoma, and localizing the pathology before surgical decompression. Nevertheless, MRI delays are possible, and reasons include scanner availability, the need for sedation, extent of the scan, patient transport and availability of a radiologist.

“So, we developed a protocol to expedite anyone who has a suspected epidural hematoma [Figure 1],” he said. “We wanted to make evaluation of this problem easier, so patients could go through the process quicker and not fall through the cracks.”

The anesthesiologist who suspects an evolving epidural hematoma in a patient initiates the protocol, and several things occur simultaneously. MRI suite personnel make one of the scanners available for the patient, and the in-house radiologist is notified of the need for a stat reading of the scan. The neurosurgery staff is emergently consulted about the possibility of a laminectomy, and operating room personnel are contacted to ensure space is made available for the patient, if necessary.

“The physician then physically transports the patient to the MRI suite,” Dr. Gupta said. “This is considered a level 1 emergency, and we need to act quickly. We don’t wait for patient transport anymore.”

An abbreviated MRI scan—limited to the affected part of the spine—is then performed. Only T1, T2 and short tau inversion recovery (STIR) sagittal sequences are acquired, a procedure that takes less than 30 minutes. “Radiology has told us that these are the key images we need to detect hematoma and spinal cord compression [Figure 2],” he said. “The MRI is read immediately by a radiologist, and the patient is transported directly to the operating room, if necessary.”

Since the implementation of the protocol, two patients with suspected epidural hematoma have undergone treatment at the medical center: a 69-year-old man with an epidural for a hip fracture and a 53-year-old woman with a thoracic epidural after abdominal surgery. In each case, the patient went through the entire protocol in less than two hours. The scans of both patients proved negative, but as Dr. Gupta explained, in such cases the process is far more important than the product. “We shouldn’t balk in making the decision to get the scan done.

“In my mind, the model is like that for appendectomy,” he said. “You want a certain rate of false-negatives. And with the amount of anticoagulation being used, I think that something like this is more important now than it ever has been. I hope we have lots of negative scans, because we don’t want to miss the positive ones.”

Richard W. Rosenquist, MD, director of the Center for Pain Medicine and Regional Anesthesia at the University of Iowa in Iowa City, agreed that the protocol could play an important role. Regardless of the reason for the development of an epidural hematoma, time is of the essence in its diagnosis and treatment, he said. “A well-defined protocol that cuts through the red tape and bureaucracy and leads to a rapid diagnosis and appropriate treatment is extremely important. The more rapidly an epidural hematoma is diagnosed and treated, the greater the chances are that the patient will recover.”

Dr. Rosenquist said that unfortunately, even in patients who undergo rapid diagnosis and treatment, a perfect recovery is not always possible. This type of protocol will certainly improve the chance for a successful outcome, he said. “The protocol as described should not be that difficult to implement, especially as it resembles other initiatives in place in many hospitals, such as a rapid-response team or a code stroke team.”