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

Abstract

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.

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report -

“…LBP, which is the most common health problem, causes pain and radiculopathy as a result of nerve irritation and inflammation. Many studies have shown that injecting the appropriate drugs through the epidural space can help relieve radiculopathy pain [ 2 ]. This procedure has very rarely caused life-threatening complications, including increased neurological deterioration, intravascular injections, cerebrospinal fluid fistulas, persistent positional headaches, arachnoiditis, hydrocephalus, air embolisms, urinary retention, allergic reactions, stroke, blindness, hematomas, and seizures [ 3 ].…”

“…Spinal epidural venous plexus is usually located at the posterior of the dural sac, so progressive motor and sensory damage often appear delayed [ 9 ]. Kim et al [ 2 ] reported on a spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site. They suggested the increasing pressure in the epidural space caused the hematoma rather than direct needle injury.…”

“…Also, spinal and epidural procedures in combination with anticoagulation were the fifth-most common cause of epidural hematoma. Additional risk factors are age, anatomic abnormalities of the spinal cord and vertebral column, needle size, traumatic needle or catheter placement, epidural techniques being used instead of spinal techniques, indwelling epidural catheters during low molecular weight heparin administration [ 7 , 8 ] and increasing pressure in the epidural space [ 2 ]. In the cases in this report, epidural hematomas developed despite adequate discontinuation of anticoagulants in both patients.…”

“…Known serious complications after epidural anesthesia, such as epidural hematoma, abscesses, and arachnoiditis, are uncommon with a reported incidence of approximately 1/150,000. However, the prevalence after transforaminal epidural steroid injection (TFESI) has not been studied [ 2 ]. We report on two patients who developed acute, severe back pain without neurological deficits after receiving TFESI due to large amounts of epidural hematoma.…”

“…Epidural hematomas with neurological symptoms are most frequently treated with decompressive laminectomy. There are only a few reported cases of treating them with non-surgical epidural aspiration [2,[11][12][13]. In the absence of neurological deficits, nonsurgical management of epidural hematoma in hemophilia teenagers have also been reported [14].…”