Will a subdural hematoma at the site of spinal anesthesia present with pain at the site?

Subdural Hematoma After Spinal Anesthesia: Pain Presentation

A subdural hematoma at the site of spinal anesthesia typically does NOT present with localized back pain at the puncture site; instead, it manifests as severe, persistent headache that is often the first and most prominent symptom. 1, 2, 3

Key Clinical Distinction

The critical distinction here is between spinal (epidural) subdural hematoma versus intracranial subdural hematoma following spinal anesthesia:

Intracranial Subdural Hematoma (More Common Complication)

• Severe, persistent headache is the hallmark presenting symptom, not localized back pain 1, 2, 3, 4
• This headache differs from typical post-dural puncture headache (PDPH) in that it may not improve with lying supine and progressively worsens 4
• The headache can be accompanied by nausea, altered consciousness, seizures, or focal neurological deficits 2, 3
• This complication develops from CSF leakage causing intracranial hypotension, leading to traction on bridging veins and subsequent intracranial bleeding 5
• Onset can occur days to weeks after the procedure (reported cases at 5 days, 20 days, and 1 month post-procedure) 1, 4, 6

Spinal Epidural Hematoma (Different Entity)

• Localized back pain is indeed the first symptom when the hematoma is at the spinal level 5, 7
• This pain is typically described as deep-seated and may be associated with localized tenderness at the puncture site 5, 7
• Radiculopathy with radiating or lancinating pain follows 7
• Progressive neurological deficits in lower extremities (paraparesis progressing to paraplegia) develop subsequently 7
• This represents a true spinal cord compression emergency requiring evacuation within 8-12 hours 5, 7, 8

Critical Diagnostic Approach

When evaluating post-spinal anesthesia complications:

• Headache predominant → Consider intracranial subdural hematoma; obtain brain CT or MRI immediately 1, 2, 3, 4
• Back pain with neurological deficits → Consider spinal epidural hematoma; obtain spine MRI urgently 5, 7
• Do not delay imaging if clinical suspicion exists, as both conditions can cause irreversible damage without prompt intervention 5, 7, 3

Common Pitfalls

• Mistaking intracranial subdural hematoma for simple PDPH because both present with headache 1, 3
• The key differentiator: PDPH improves with lying flat, while subdural hematoma headache does not and progressively worsens 4
• Assuming all post-spinal complications present with back pain—intracranial subdural hematoma does not 1, 2, 3
• Delayed recognition when headache persists beyond typical PDPH timeframe or is unrelieved by conservative measures 3, 4