Acute Spinal Epidural Hematoma as a Complication of Dry Needling: A Case Report

Berrigan, William A.; Whitehair, Curtis L.; Zorowitz, Richard D.

doi:10.1016/j.pmrj.2018.07.009

Cited by 14 publications

(8 citation statements)

References 8 publications

(11 reference statements)

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“…Other incidents (less frequent) reported in the literature but not less important are cardiac tamponade [21,39,51,75,77], granulomas [23], fistulas [24,38], necrosis [25,42,85], infections [27,57,119], abscesses [27,45,61,71,74,76], pneumoretroperitoneum [32], hemorrhages [35], hemopericardium [37], haematomas [40,64,67,109,111,117], chilotorax [41], organ perforation [48,60], needle rupture [53,55,117], hemiplegia [54], hemothorax [56], peritonitis [66], cellulitis [72], hypokalemic paralysis [84], nerve injury [86,99,102,107,108,110,116], weakness …”

Section: Most Prevalent Adverse Effectsmentioning

confidence: 99%

Needling Therapies in the Outpatient Care: Adverse Effects

Llamas-Ramos¹,

Llamas-Ramos²

2022

Ultimate Guide to Outpatient Care

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The invasive techniques have been used for many years. There is a lot of literature on the advances that have been made, as well as the adverse effects or possible complications that have occurred during the performance of these treatments. Acupuncture and injections (saline, anesthetics, corticosteroids or botulinum toxin) have reported several cases of complications. Dry needling is also beginning to have several publications of this type. The objective of this chapter is to summarize the articles published in relation to adverse effects of needling therapies to promote a good practice and knowledge. Original articles in form of randomized controlled trials, case reports and reviews relating adverse effects and possible complications due to invasive/needling techniques: acupuncture, injections and dry needling have been included. 102 articles met the inclusion criteria between January 2000 and January 2020. The first limitation found in the literature was the huge variety of cases, therapists and incidents to generalize. As a conclusion we can stated the importance of a good knowledge of the anatomy and its variants, the correct application of these techniques and a continuous training of these therapists must be essential.

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Section: Most Prevalent Adverse Effectsmentioning

confidence: 99%

Needling Therapies in the Outpatient Care: Adverse Effects

Llamas-Ramos¹,

Llamas-Ramos²

2022

Ultimate Guide to Outpatient Care

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“…Table 6 shows reports of bleeding and epidural hematoma associated with interventional techniques in patients without antithrombotic therapy (136,138,140,144,180,183,185,190,(192)(193)(194)(195)197,201,203,204,206,208,209), whereas Table 7 shows reports of bleeding in patients with discontinued antithrombotic therapy (130,(133)(134)(135)138,139,148,181,(187)(188)(189)191).…”

Section: Case Reports Of Bleeding Complicationsmentioning

confidence: 99%

“…Although the overall incidence of bleeding complications and epidural hematoma in the non-obstetric epidural literature has been reduced, the incidence has been higher with procedures involving cervical and thoracic spine (1,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(52)(53)(54)129). Of note, the clinical literature reports of incidences of epidural hematoma cases accompanying interventional techniques and neuraxial techniques are increasing rapidly (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(130)(131)(132)(133)(134)(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)…”

Section: Introductionmentioning

confidence: 99%

“…Of note, the clinical literature reports of incidences of epidural hematoma cases accompanying interventional techniques and neuraxial techniques are increasing rapidly (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(130)(131)(132)(133)(134)(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149). While some reports indicate a decreasing incidence of bleeding complications related to neuraxial techniques (145), multiple studies have been performed assessing the prevalence and risks related to bleeding complications and epidural hematoma with neuraxial procedures, specifically interventional techniques (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)...…”

Section: Introductionmentioning

confidence: 99%

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Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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Background: Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. Study Design: Best evidence synthesis. Objective: To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. Methods: A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. Results: 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors. 2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety. 5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae. 6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure. 7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant. 8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma. 9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy. 11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed. 12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas. 13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. Limitations: The continued paucity of the literature with discordant recommendations. Conclusion: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain

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“…Clinicians should ensure adequate hemostasis in this at-risk population. For instance, two case reports describe acute cervical epidural hematoma after dry needling of the cervical multifidus [32,33]. Although not directly related to the presence of vascular disease in these particular patients, dry needling of a patient with a comorbid vascular condition could further complicate a more serious adverse event such as epidural hematoma.…”

Section: Cardiovascular and Hematologic Diseasementioning

confidence: 99%

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Kearns

Fernández‐de‐las‐Peñas

Brismée

et al. 2019

Journal of Manual & Manipulative Therapy

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Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

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Acute Spinal Epidural Hematoma as a Complication of Dry Needling: A Case Report

Cited by 14 publications

References 8 publications

Needling Therapies in the Outpatient Care: Adverse Effects

Needling Therapies in the Outpatient Care: Adverse Effects

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

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