Epidural hematoma after epidural block: implications for its use in pain management

doi:10.1016/S0090-3019(02)00639-0

Surgical Neurology

Volume 57, Issue 4, April 2002, Pages 235-240

https://doi.org/10.1016/S0090-3019(02)00639-0 Get rights and content

Abstract

BACKGROUND

Spinal epidural hematoma after spinal puncture such as for injection of steroids for pain management may result in a rare complication of a spinal epidural hematoma causing acute myelopathy. Although this complication is well known with epidural anesthesia, where it is usually seen with impaired hemostasis, there are surprisingly few case reports of epidural hematoma after an epidural steroid block.

CASE DESCRIPTION

A healthy 34-year-old man with no evidence of coagulopathy and not taking antiplatelet medication suddenly had onset of acute cervical myelopathy from a large cervical epidural hematoma 8 days after a cervical epidural steroid block. Following prompt surgical evacuation of the clot, the patient made a near complete recovery.

CONCLUSION

Spinal epidural hematoma after spinal puncture is usually associated with impaired hemostasis. This case illustrates that it may occur in the absence of known risk factors. The delayed onset and the absence of risk factors have implications for the use of this procedure in chronic pain management.

Section snippets

Case report

A 34-year-old man, otherwise in excellent health, was brought to the emergency department because of abrupt onset of severe neck pain and left-sided weakness. He had been under treatment in an outlying community for chronic neck and shoulder pain attributed to an automobile accident occurring 18 months previously. After that accident, a cervical magnetic resonance imaging (MRI) scan had shown a midline disc bulge at the C3-C4 interspace. He had been treated with physical therapy and

Cases from the literature

Williams et al [52] describe an epidural hematoma after epidural steroid injection in a 63-year-old man with chronic pain from spondylosis taking indomethacin and allopurinol. The injection was performed at the C7-T1 interspace with a 16-gauge Tuohy needle without difficulty. It was the seventh such injection performed at 3 to 4 month intervals. Twenty minutes later, he had intense pain at the injection site and across both shoulders. Some 45 minutes later he had flaccid paralysis and at

Discussion

Spinal epidural hematoma has been ascribed to a diverse etiology. It has been reported after lumbar puncture 33, 37, 38, myelography [29], and epidural anesthesia usually in conjunction with anticoagulation 2, 7, 10, 27, 28, 35, 44, 56. In addition to those cases occurring after some form of spinal puncture, cases have been reported in the setting of anticoagulation therapy [20], hemophilia, neoplasia, vascular malformations 13, 34, trauma 14, 58, spinal surgery [48], thrombolysis for

Conclusion

The incidence of epidural hematoma after epidural block is rare, and may be comparable to the risk of epidural hematoma after epidural anesthesia where it has been cited as one in 190,000 anesthetics. Nevertheless, the complication can occur even in the absence of any known risk factors. Furthermore, the risk period for its development is not hours or days, but as long as a week. Consideration as to availability of neurosurgical intervention seems prudent because only prompt surgical

References (58)

H.T. Benzon
Epidural steroid injection for low back pain and lumbosacral radiculopathy
Pain
(1986)
J.E. Cohen et al.
Fatal spontaneous spinal epidural hematoma following thrombolysis for myocardial infarction
Surg Neurol
(1998)
D. Foo et al.
Preoperative neurological status in predicting surgical outcome of spinal epidural hematoma
Surg Neurol
(1981)
R.J.M. Groen et al.
The spontaneous spinal epidural hematomaa study of etiology
J Neur Sci
(1990)
T.T. Horlocker et al.
Anticoagulation and neuraxial blockhistorical perspective, anesthetic implications, and risk management
Reg Anesth Pain Med
(1998)
J.S. Huff
Spinal epidural hematoma associated with cocaine abuse
Am J Emerg Med
(1994)
L. Landow et al.
Low-molecular weight heparin, spinal hematomas, and the FDAwhat’s wrong with this picture?
Reg Anesth Pain Med
(1999)
J. Peltola et al.
Spinal epidural haematoma complicating diagnostic lumbar puncture
Lancet
(1996)
D.B. Scott et al.
Serious non-fatal complications associated with extradural block in obstetric practice
Brit J Anaesth
(1990)
S. Stephanov et al.
Lumbar epidural hematoma following epidural anesthesia
Surg Neurol
(1982)

M. Swerdlow

Medicolegal aspects of complications following pain relieving blocks

Pain

(1982)

K.N. Williams et al.

Epidural hematoma requiring surgical decompression following repeated cervical epidural steroid injections for chronic pain

Pain

(1990)

Major complications in continuous epidural anesthesia

Chin Med J

(1980)

R.F. Armstrong et al.

Epidural and spinal anaesthesia and the use of anticoagulants

Hosp Med

(1999)

R.M. Beatty et al.

Spontaneous cervical epidural hematomaa consideration of etiology

J Neurosurg

(1984)

F.W. Brown

Management of diskogenic pain using epidural and intrathecal steroids

Clin Orthop

(1977)

J.H. Brown

Pressure caudal anesthesia and back manipulation

Northw Med (Seattle)

(1960)

A.B. Butler et al.

Hematoma following epidural anesthesia

Can Anaesth So J

(1970)

R.F.H. Catchlove et al.

The use of cervical epidural nerve blocks in the management of chronic head and neck pain

Can Anaesth Soc J

(1984)

C.A. Dickman et al.

Spinal epidural hematoma associated with epidural anesthesiacomplications of systemic heparinization in patients receiving peripheral vascular thrombolytic therapy

Anesthesiology

(1990)

J.H. Dougherty et al.

Complications following intraspinal injection of steroids

J Neurosurg

(1978)

R.D. Dripps et al.

Long-term follow-up of patients who received 10,098 spinal anesthetics

JAMA

(1954)

D.W. Eastwood

Hematoma after epidural anesthesiarelationship of skin and spinal angiomas

Anesth Analg

(1991)

D. Foo et al.

Post-traumatic spinal epidural hematoma

Neurosurgery

(1982)

L. Franscini et al.

Evaluation of back pain secondary to spinal epidural hematoma associated with aspirin intake and a partial platelet glycoprotein Ia/Iia deficiency

Arch Int Med

(1994)

P. Ganjoo et al.

Postblock epidural hematoma causing paraplegia

Reg Anesth

(1994)

H.W. Goebert et al.

Sciaticatreatment with epidural injections of procaine and hydrocortisone

Cleveland Clin Quart

(1960)

R. Gordh et al.

The neurological sequelae of anesthesia (cases 48–60)

Int Anesthesiol Clin

(1975)

T.F. Gringrich

Spinal epidural hematoma following continuous epidural anesthesia

Anesthesiology

(1968)

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Caudal epidural sacral injection is one of the most common conservative treatments for chronic low back pain with radiculopathy. Neurological deficit after injection is a rare complication that must be identified and treated properly.
We report a case of cauda equina syndrome that persisted until 3 months after injection. A 63-year-old man came to our department with severe lumbar canal stenosis who experienced motor weakness, buttocks numbness and voiding difficulties immediately after injection. His lower extremities improved after 24 h, but his neurogenic bladder problems and perianal numbness still persisted. We collaborated with our interdisciplinary teams to do a rehabilitation program, and the symptoms were alleviated and he fully recovered within three months.
Patients with severe stenosis can be best described from magnetic resonance imagery scans, and clinicians should be careful about the risks after injection ranging from transient complications to persistent spinal cord injury.
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These include procedure-related pain and steroid side effects.3 That said, both approaches also have risks of more serious complications, such as neurologic damage.4–15 Each approach is unique in the potential etiology of causing such damage, however, and accordingly risk-mitigation techniques for either approach differ.
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A P < 0.05 indicated statistical significance. A sum of 147 published articles, case reports or letters [11–157], describing altogether 169 cases relevant for this review were found. Three of these were excluded: a newborn child with multiple malformations, who developed a subdural spinal haematoma after a lumbar epidural catheter [155], and two patients where the cause of the haematoma was uncertain [156,157].
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated: (1) Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase. Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
Facet joint injection versus epidural steroid injection for lumbar spinal stenosis: intra-individual study
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Epidural steroid injection (ESI) is used for the management of central canal stenosis giving pain relief for several weeks to several months.1 There has been a steady increase in ESI treatment for central canal stenosis over the past two decades1,2; however, ESI can cause rare but significant complications, including spinal cord infarction.3–8 Epidural haematoma induced by ESI can cause severe thecal sac compression or permanent neurological deficit.3,8
To evaluate the efficacy of facet joint injection (FJI) for patients with lumbar central canal stenosis (LCS) in comparison with epidural steroid injection (ESI) in the same individuals.
Two hundred and fifty-two patients who underwent both FJI and ESI for LCS between January 2014 and December 2014 were considered for enrolment in the study. A radiologist retrospectively conducted a chart review and recorded which injection was chosen as the third injection after sequential injections of FJI and ESI, and why clinicians chose the particular injection method. The response was measured via the use of a five-point satisfaction scale.
Among 252 patients, only 73 patients were included in the study (the remaining patients did not fulfil the inclusion criteria). Out of 73 patients (mean age, 69.7 years; range, 49∼87 years), 50 patients had received a third injection, 33 patients (66%) underwent FJIs as a third injection. Out of 19 patients who had experienced an ineffective first ESI, 13 (68.4%) patients reported the second FJI as effective. Out of six patients for whom the first FJI had been ineffective, three (50%) patients reported the second ESI as effective.
FJIs can be administered as an alternative to ESIs in cases of LCS.
Three cases of hemiplegia after cervical paraspinal muscle needling
2015, Spine Journal
Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood.
We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications.
Case report.
The authors retrospectively reviewed the medical charts from a decade (2002-2013) at Korea University Hospital. The records were systematically searched, and the cases with hemiplegia (grade<3) after needing therapy were collected. No conflict of interest reported. No funding received.
A 54-year-old woman, a 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture, or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially.
Spinal hematoma after muscle needling is unusual but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.
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Original articleEpidural hematoma after epidural block: implications for its use in pain management

Abstract

Section snippets

Case report

Cases from the literature

Discussion

Conclusion

Pain

Surg Neurol

Surg Neurol

J Neur Sci

Reg Anesth Pain Med

Am J Emerg Med

Reg Anesth Pain Med

Lancet

Brit J Anaesth

Surg Neurol

Pain

Pain

Major complications in continuous epidural anesthesia

Chin Med J

Epidural and spinal anaesthesia and the use of anticoagulants

Hosp Med

Spontaneous cervical epidural hematomaa consideration of etiology

J Neurosurg

Management of diskogenic pain using epidural and intrathecal steroids

Clin Orthop

Pressure caudal anesthesia and back manipulation

Northw Med (Seattle)

Hematoma following epidural anesthesia

Can Anaesth So J

The use of cervical epidural nerve blocks in the management of chronic head and neck pain

Can Anaesth Soc J

Spinal epidural hematoma associated with epidural anesthesiacomplications of systemic heparinization in patients receiving peripheral vascular thrombolytic therapy

Anesthesiology

Complications following intraspinal injection of steroids

J Neurosurg

Long-term follow-up of patients who received 10,098 spinal anesthetics

JAMA

Hematoma after epidural anesthesiarelationship of skin and spinal angiomas

Anesth Analg

Post-traumatic spinal epidural hematoma

Neurosurgery

Evaluation of back pain secondary to spinal epidural hematoma associated with aspirin intake and a partial platelet glycoprotein Ia/Iia deficiency

Arch Int Med

Postblock epidural hematoma causing paraplegia

Reg Anesth

Sciaticatreatment with epidural injections of procaine and hydrocortisone

Cleveland Clin Quart

The neurological sequelae of anesthesia (cases 48–60)

Int Anesthesiol Clin

Spinal epidural hematoma following continuous epidural anesthesia

Anesthesiology

Original article
Epidural hematoma after epidural block: implications for its use in pain management