Wilkinson, AJ; Osborne, AT; Kovitz, CA., Chai, T; Huh BK
The performance of any neuraxial procedure carries an inherent risk of neurologic damage. Bleeding is of great concern in these procedures, as occult spinal epidural hematoma formation in these procedures carries the risk of causing significant neurologic deficits. While the development of spinal epidural hematomas in neuraxial interventions is estimated to be extremely low, the anatomy, medications, and other factors need to be carefully considered along with close adherence to established guidelines for patient safety are necessary to minimize the risk in every patient. We present an 84-year-old woman on secondary anticoagulation with aspirin who underwent a low-risk neuraxial procedure that presented one week later with significant neurologic impairment and pain due to a spinal epidural hematoma requiring emergency decompressive surgery for hematoma evacuation.
Epidural hematoma after neuraxial pain interventions is rare, the earliest estimate of this complication suggested an incidence of 1:200,000 after a spinal block and 1:150,000 after an epidural block for all patients.1 While risk factors, including the presence of anticoagulants, multiple punctures needed during the procedure, and anatomical variations in vertebral processes, have been demonstrated, case reports have described the formation of spinal epidural hematoma after neuraxial procedures without these traditional risk factors.2 Yet, the complicated care of patients with oncologic processes that induce potential coagulopathy raises the need for further consideration of this complication when considering performing neuraxial procedures. We present the case of an 84-year-old female with an oncologic history of multiple myeloma who presented to the hospital one week after a lumbar spine pain procedure, found to have an epidural hematoma causing severe spinal stenosis necessitating emergency lumbar laminectomy for hematoma evacuation.
An 84-year-old female with a past medical history of multiple myeloma, on maintenance therapy, and a history of lumbar spondylosis, was admitted for severe low back pain and difficulty walking. At that time, she was noted to be on 81 mg of aspirin daily. On admission, she underwent a lumbar “nerve ablation” procedure by a local pain doctor the week prior.
Lumbar imaging by Magnetic Resonance Imaging (MRI) for workup demonstrated a dorsal epidural hematoma at L2, resulting in several central spinal canal stenosis. In the T1 sequence, there was an intrinsic hyperintensity estimated to be 10 mm in the AP dimension and 6 cm in the cranial-caudal dimension which contributed to the several spinal canal stenosis at L2 with constriction of the caudal equina. No cord signal abnormality was detected. Post-contrast imaging demonstrated minimal peripheral enhancement of the dorsal epidural collection. (Figures 1 and 2)
The patient then underwent an emergency evacuation of the epidural hematoma via L2-L4 laminectomy by the Neurosurgery service, without any complications. Postoperatively, she reported significant improvement in her pain and regained the ability to walk at baseline with her walker.
Any neuraxial procedure carries with it risks, which include vasovagal syncope, post-dural puncture headaches, infections, and bleeding (hematoma formation),4 among others. The incidence of any general neuraxial blockade (GNB) complication is estimated to be between 1/1000 and 1/1,000,000.5 These risks should be considered in every patient, especially in patients carrying the additional risk factors aforementioned in this report.
Spinal epidural hematoma (SEH) resulting from neuraxial procedures is a rare complication seen in pain management. The estimated prevalence of SEH is 1:200,000 after a spinal block and 1:150,000 after an epidural block for all patients.1 Notably, this estimation does not specify or account for particular risk factors, like coagulopathy, anatomical variations, or technical errors in performing the procedure. Thus, one can infer that a patient without any notable risk factors or any technical errors in performing the procedure would have a smaller risk of complications. This patient stated that she underwent a lumbar “nerve ablation” procedure; therefore, it is unclear what specific procedure was done; however, SEH after nerve ablation procedures appears to have been described in the literature.3
The American Society of Regional Anesthesia’s (ASRA) guidelines for avoiding neurological damage in neuraxial procedures identify the importance of proper imaging and documentation of patient-specific anatomy, avoidance of conditions that lead to increased bleeding, principally concurrent use of anticoagulants or imminent use of anticoagulants, use of proper sterile technique, avoidance of overdosing of local anesthetic during the procedure, and that the procedures be done in a setting capable of necessary resuscitation in the event of serious complications.6 Furthermore, ASRA outlines recommended durations of discontinuation necessary for all classes of anticoagulants and the recommended wait period before restarting of the medication after various neuraxial procedures. These recommendations require physician interpretation of the relative risk of bleeding involved in each procedure, as holding parameters for anticoagulants vary depending on this perceived risk. For this patient, a “high-risk” procedure would require six days of discontinuation of aspirin if for primary anticoagulation, but shared assessment if for secondary anticoagulation or any procedure less than “high-risk.” This further highlights the necessity of this report demonstrating the possibility of spinal epidural hematoma formation even in a lower-risk procedure and patient. All the risks should be considered for each patient, regardless of the level of risk of the procedure, the number of times the procedure has been performed on that patient, or their pharmacologic history.
Preventing neurologic and hematologic complications in patients undergoing neuraxial procedures remains a top priority within the field of interventional pain management. Even in low-risk patients undergoing low-risk procedures, there is still a chance of potentially devastating complications such as the formation of a spinal epidural hematoma resulting in neurologic injury. This case demonstrates the need for a careful review of each patient’s history, anatomy, and risk factors combined with adherence to published guidelines and close follow-up to minimize the development of bleeding complications after neuraxial procedures.
- Chan L, Bailin MT. Spinal epidural hematoma following a central neuraxial blockade and subcutaneous enoxaparin: a case report. J Clin Anesth. 2004 Aug;16(5):382-5. doi:10.1016/j.jclinane.2004.05.001. PMID: 15374561.
- Nam KH, Choi CH, Yang MS, Kang DW. Spinal epidural hematoma after pain control procedure. J Korean Neurosurg Soc. 2010 Sep;48(3):281-4. doi:10.3340/jkns.2010.48.3.281. Epub 2010 Sep 30. PMID: 21082060; PMCID: PMC2966734.
- Kim SW, Chang MC. Epidural hematoma after caudal epidural pulsed radiofrequency stimulation: A case report. Medicine (Baltimore). 2018 Nov;97(45):e13090. DOI:10.1097/MD.0000000000013090. PMID: 30407313; PMCID: PMC6250492.
- Alkhudari AM, Malk CS, Rahman A, Penmetcha T, Torres M. Epidural hematoma after routine epidural steroid injection. Surg Neurol Int. 2016 May 6;7:55. DOI: 10.4103/21527806.181906. PMID: 27213109; PMCID: PMC4866065.
- Agarwal A, Kishore K. Complications and controversies of regional anaesthesia: a review. Indian J Anaesth. 2009 Oct;53(5):543-53. PMID: 20640104; PMCID: PMC2900086.
- Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, Mulroy MF, Rosenquist RW, Rowlingson J, Tryba M, Yuan CS. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003 May-Jun;28(3):172-97. DOI: 10.1053/rapm.2003.50046. PMID: 12772135.
Figure 1: MRI Lumbar Spine T1 Sequence, Sagittal Section. Annotated arrowheads demonstrating epidural hematoma.
Figure 2: MRI Lumbar Spine T2 Sequence, Sagittal section (left) and Transverse section (right). Arrows showing the location of the epidural hematoma in both views