Lumbar neuraxial procedures in thrombocytopenic patients across populations: A systematic review and meta-analysis

Melissa E Bauer; Roulhac D Toledano; Timothy Houle; Yaakov Beilin; Mark MacEachern; Madeline McCabe; Dana Rector; Jason P Cooper; Terry Gernsheimer; Ruth Landau; Lisa Leffert

doi:10.1016/j.jclinane.2019.109666

Lumbar neuraxial procedures in thrombocytopenic patients across populations: A systematic review and meta-analysis

J Clin Anesth. 2020 May:61:109666. doi: 10.1016/j.jclinane.2019.109666. Epub 2019 Dec 4.

Authors

Affiliations

¹ Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA. Electronic address: mbalun@med.umich.edu.
² Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA. Electronic address: Roulhac.Toledano@nyulangone.org.
³ Department of Anesthesiology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA. Electronic address: thoule1@mgh.harvard.edu.
⁴ Department of Anesthesiology, Perioperative and Pain Medicine Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA. Electronic address: yaakov.beilin@mountsinai.org.
⁵ Taubman Health Sciences Library, University of Michigan Medical School, 1135 Catherine St, Ann Arbor, MI 48109, USA. Electronic address: markmac@umich.edu.
⁶ Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA. Electronic address: mmmccabe@umich.edu.
⁷ Department of Anesthesiology, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA. Electronic address: rectdan@umich.edu.
⁸ Division of Hematology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA. Electronic address: jpcooper@fredhutch.org.
⁹ Division of Hematology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA. Electronic address: bldbuddy@u.washington.edu.
¹⁰ Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA. Electronic address: rl262@cumc.columbia.edu.
¹¹ Department of Anesthesiology, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA. Electronic address: lleffert@mgh.havard.edu.

PMID: 31810860
DOI: 10.1016/j.jclinane.2019.109666

Abstract

Introduction: There is currently no consensus regarding the minimum threshold platelet count to ensure safe neuraxial procedures. Numerous reports describe the safe performance of lumbar punctures in severely thrombocytopenic patients but reports of neuraxial anesthetic procedures in thrombocytopenic patients are limited. To date, the focus on specific populations in contemporary reviews has failed to include any actual hematoma cases. This systematic review aggregates reported lumbar neuraxial procedures from diverse thrombocytopenic populations to best elucidate the risk of spinal epidural hematoma.

Methods: MEDLINE, Embase, Cochrane, CINAHL databases were searched for articles about thrombocytopenic patients (<100,000 × 10⁶/L) who received a lumbar neuraxial procedure (lumbar puncture; spinal, epidural, or combined spinal-epidural analgesia/anesthesia; epidural catheter removal), whether spinal epidural hematoma occurred.

Results: Of 4167 articles reviewed, 131 met inclusion criteria. 7476 lumbar neuraxial procedures were performed without and 33 procedures with spinal epidural hematoma. Within the platelet count ranges of 1-25,000 × 10⁶/L, 26-50,000 × 10⁶/L, 51-75,000 × 10⁶/L, and 76-99,000 × 10⁶/L there were 14, 6, 9, and 4 spinal epidural hematomas, respectively. An infection point and narrow confidence intervals were observed near 75,000 × 10⁶/L or above, reflecting a low probability of spinal epidural hematoma in this sample. Of the 19 spinal epidural hematoma cases for which the onset of symptoms was reported, 18 (95%) were symptomatic within 48 h of the procedure.

Conclusions: Spinal epidural hematoma in thrombocytopenic patients is rare. In this sample of patients, an inflection point and narrow confidence intervals are observed near a platelet count of 75,000 × 10⁶/L or above, reflecting an estimated low spinal epidural hematoma event rate with more certainty given a larger sample size and inclusion of spinal epidural hematoma cases. Thrombocytopenic patients should be monitored, particularly in the first 48 h, and educated about symptoms concerning for spinal epidural hematoma.

Keywords: Analgesia, epidural; Anesthesia, spinal; Hematoma, epidural, spinal; Platelet count; Spinal puncture.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Anesthesia, Epidural* / adverse effects
Anesthesia, Spinal*
Hematoma, Epidural, Spinal* / epidemiology
Hematoma, Epidural, Spinal* / etiology
Humans
Platelet Count
Spinal Puncture / adverse effects

Grants and funding

T32 HL007093/HL/NHLBI NIH HHS/United States