Anaes · Regional anaesthesia
Neuraxial complications: PDPH, haematoma and high spinal
Also known as Post-dural puncture headache · Epidural haematoma · High spinal · Total spinal · Epidural blood patch · Epidural abscess
Exam-exhaustive neuraxial complications: PDPH diagnosis and blood-patch volumes, epidural haematoma red flags and ASRA timing principles, high/total spinal drill, abscess, and emergency imaging pathway for ANZCA Final and equivalents.
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Red flags
- Severe new back pain + progressive neurology after neuraxial block = haematoma or abscess until MRI and surgical review prove otherwise — hours matter.
- Postural headache after dural puncture = PDPH; offer blood patch when severe/persistent (typical autologous volume ~15–20 mL, titrated).
- Rapid ascending block with hypotension, bradycardia, respiratory failure = high/total spinal — ventilate, support circulation, wait for regression.
- Respect anticoagulant timing for puncture and catheter removal (ASRA) — haematoma is the preventable catastrophe.
- Fever + back pain + neurology = abscess pathway, not 'musculoskeletal backache.'
Meet the patient
Day one after an uneventful epidural for bowel surgery, the nurse phones you at 2am. The patient has severe new back pain and 'her legs feel strange'. On the ward she cannot lift them. The epidural infusion is still running.[4]
That phone call is the moment neuraxial competence is judged. The wrong response is physio and analgesia overnight; the right response is to treat it as a compressive lesion — stop the infusion, image urgently, call the surgeons. Hours, not days, separate a walking patient from a paraplegic one.[4]
References7ShowHide
- [1]Kopp SL, Vandermeulen E, McBane RD, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition). Reg Anesth Pain Med, 2025.PMID 39880411
- [2]Konduru RA, Shabnam A, Yarmush J, et al. Post-dural Puncture Headache: Pathophysiology, Risk Stratification, Prevention, and Evidence-Based Management for Practicing Anesthesiologists. Cureus, 2026.PMID 42099352
- [3]Berger AA, Armstrong SL, Li Y, et al. Association Between Injected Volume and Epidural Blood Patch Success on Obstetric Post-Dural-Puncture Headache: A Retrospective Cohort Study. Anesth Analg, 2026.PMID 41666403
- [4]Grace K, Schuster NM, Smith CC International Pain and Spine Intervention Society Emergency Protocols: Epidural Hematoma. Interv Pain Med, 2026.PMID 42306256
- [5]Xu BS, et al. Anesthetic complications of extensive spinal nerve block and total spinal anesthesia during percutaneous endoscopic spinal surgery under local anesthesia. Eur Spine J, 2026.PMID 42289523
- [6]Rodriguez J, Hoffman S Thoracic Spinal Epidural Abscess After Spinal Cord Stimulation Trial With Cord Compression but Preserved Neurologic Function: A Rehabilitation Case. Cureus, 2026.PMID 42359233
- [7]Neal JM, Barrington MJ, Brull R, et al. The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015. Reg Anesth Pain Med, 2015.PMID 26288034