Twisted epidural catheter mimicking epidural hematoma in a hemophilic patient: a case report

Epidural anesthesia is generally avoided in patients with hemophilia due to the risk of spinal or epidural hematoma. However, with careful factor replacement and perioperative management, neuraxial techniques may be feasible in selected cases. Mechanical complications, such as catheter twisting, are rare but can mimic serious neurological events, requiring careful differential diagnosis.

A 37-year-old man with severe hemophilia A and factor VIII inhibitors underwent bilateral total knee arthroplasty (TKA) under epidural anesthesia. He received recombinant activated factor VIIa (rFVIIa) and tranexamic acid for hemostatic management. Postoperatively, he developed left leg weakness and paresthesia. Emergency MRI ruled out hematoma but revealed a twisted epidural catheter at L4-L5. The catheter was promptly removed after rFVIIa administration, and conservative treatment led to complete recovery within 3 months.

This case highlights the rare mechanical complication of epidural catheter twisting in a high-risk hemophilia patient, mimicking epidural hematoma. It highlights the importance of timely imaging, individualized risk-benefit assessments, and adherence to safety protocols for neuraxial anesthesia (NA) in individuals with hemophilia. Comparison with existing guidelines and limited case reports emphasizes the need for standardized protocols and vigilant postoperative monitoring.

NA can be safely used in selected patients with hemophilia, provided that rigorous hemostatic management is employed. Mechanical complications like catheter twisting, though rare, should be considered in the differential diagnosis of postoperative neurological deficits, and robust monitoring protocols should be implemented.