Delayed and recurrent thoracic epidural haematoma after spinal anaesthesia in a patient with factor XIII deficiency

Spinal epidural haematoma after spinal anaesthesia is rare but may cause severe neurological injury. We report the case of an 85-year-old man who developed a delayed thoracic spinal epidural haematoma following uncomplicated single-shot spinal anaesthesia for elective endovascular aortic repair. Low-dose intravenous unfractionated heparin was administered 73 minutes after the spinal puncture. Seventy-two hours after surgery, the patient developed acute bilateral lower-limb weakness, back pain, loss of perineal sensation and urinary retention. Magnetic resonance imaging revealed a posterior thoracic epidural haematoma from T7 to T12; urgent T8-T12 hemilaminectomy was then performed. Despite partial neurological recovery, seven days later, the patient developed sudden back pain and complete paraplegia. Repeat imaging showed recurrent epidural haematoma from T6 to T12, requiring repeat decompression. Standard coagulation tests and rotational thromboelastometry remained within normal limits throughout admission. Subsequent extended coagulation testing identified reduced factor XIII activity (38%). The patient remained paraplegic with persistent urinary retention after 60 days of rehabilitation. This case illustrates that delayed and recurrent spinal epidural haematoma may occur after atraumatic spinal anaesthesia despite guideline-compliant timing of unfractionated heparin and normal routine coagulation testing. In patients with unexplained delayed or recurrent neuraxial bleeding, occult disorders of clot stability should be considered.