Discordant lumbar epidural hematoma after caudal steroid injection

Choi, Jung Ju; Chang, Young Jin; Jung, Wol Seon; Lee, Kyung Cheon; Kim, Ju Ho; Jo, Youn Yi

doi:10.1097/md.0000000000007127

Cited by 12 publications

(12 citation statements)

References 19 publications

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“…There have been other reported cases where hematoma is thought to result from a similar cause. In the case reported by Choi et al, [13] epidural hematoma occurred at the L2-L4 level after caudal block. In the cases reported by Gungor and Arier, [14] post-TFESI contralateral epidural hematoma occurred in the direction of injection.…”

Section: Discussionmentioning

confidence: 99%

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

Kim¹,

Lee²,

Kim³

et al. 2019

Medicine

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Rationale: Transforaminal epidural steroid injection (TFESI) is a conservative method to treat back pain due to radiculopathy. However, epidural hematoma can occur after the procedure by various mechanisms, which can cause serious complications. Patient concerns: An 82-year-old man with spinal stenosis was treated with TFESI in the right intervertebral foramen at the L2-L3 level. The next morning, he experienced severe back pain and diffuse motor deficit. Diagnosis: Emergency magnetic resonance imaging revealed fluid collection in the posterior epidural space at the T11-L1 level with central-canal stenosis. Interventions: Emergency hematoma evacuation was performed to remove the epidural hematoma. Outcomes: After the surgery, the back pain disappeared. Lessons: Epidural hematoma may occur due to causes other than direct needle injury after TFESI. Therefore, careful observation of the patient is necessary after the procedure.

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Section: Discussionmentioning

confidence: 99%

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

Kim¹,

Lee²,

Kim³

et al. 2019

Medicine

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“…In 2017, Choi reported a lumbar epidural hematoma from the L2-S1 levels with concomitant central canal compromise at the L2/L3 and L3/L4 levels about 6 hours after caudal epidural steroid injection. [ 11 ] The patient's symptoms were completely resolved after an emergent operation.…”

Section: Discussionmentioning

confidence: 99%

Epidural hematoma after caudal epidural pulsed radiofrequency stimulation

Kim¹,

Lee

2018

Medicine

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Rationale:Epidural hematoma is a possible complication after neuraxial procedures. Recently, caudal epidural pulsed radiofrequency (PRF) stimulation was reported as an effective method for controlling several types of chronic pain. Herein, we report on a patient who developed a lumbar epidural hematoma after receiving caudal epidural PRF stimulation.Patient concerns:A 75-year-old woman, who was taking oral warfarin (2 mg/d), received caudal epidural PRF stimulation for symmetrical neuropathic pain in both legs due to chronic idiopathic axonal polyneuropathy. She did not discontinue warfarin use before undergoing the procedure. Three days and 12 hours after the procedure, motor weakness suddenly manifested in the right leg (manual muscle testing [MMT] = 2–3).Diagnoses:Lumbar magnetic resonance imaging (MRI) performed 7 days after the PRF procedure showed a spinal epidural hematoma at the L1 to L5 levels, compressing the thecal sac. The international normalized ratio was 6.1 at the time of the MRI.Interventions:Decompressive laminectomy from L1 to L5 with evacuation of the hematoma was performed.Outcomes:Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5.Lessons:This case suggests that clinicians should carefully check if patients are taking an anticoagulant medication and ensure that it is discontinued for an appropriate length of time before a caudal epidural PRF procedure is performed.

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“…Table 8 shows reports of bleeding complications and epidural hematoma in patients with continuation of antiplatelet therapy with interventional techniques. Multiple reports of bleeding complications with continuation of anticoagulant therapy during interventional techniques were identified (131)(132)(133)136,137,182,199,200,202).…”

Section: Case Reports Of Bleeding Complicationsmentioning

confidence: 99%

“…4, epidural injections were responsible for 25 cases of hematomas, 7 cases were secondary to acupuncture or dry needling and 6 were related to spinal cord stimulation. There was one case report of caudal epidural injection with cilostazol (202), and in one case report we were unable to obtain full manuscript (207). Cases of chronic subdural hematoma and cases of abdominal hematomas were not included.…”

Section: Choi Et Al (202)mentioning

confidence: 99%

“…The following classification for interventional techniques has been developed (Table 13) (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)52,53,(198)(199)(200)212). The classification describes low risk, intermediate risk, and Of all the low risk procedures as shown in Table 13, caudal epidural injection was the only one which has reported an epidural hematoma with continuation of cilostazol (202). This is extremely unusual and probably coincidental.…”

Section: Risk Stratificationmentioning

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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Discordant lumbar epidural hematoma after caudal steroid injection

Cited by 12 publications

References 19 publications

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

Epidural hematoma after caudal epidural pulsed radiofrequency stimulation

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

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