Article

Paraplegia After Thoracic Epidural Steroid Injection

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Epidural steroid injections are a common procedure performed by pain physicians. The American Society of Regional Anesthesia along with several other groups recently provided guidelines for performing epidural injections in the setting of anticoagulants. We present a case of a patient who developed an epidural hematoma and subsequent paraplegia despite strict adherence to these guidelines. Although new guidelines serve to direct practice, risks of devastating neurologic complications remain as evidenced by our case.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Transforaminal ESI have been associated with paraplegia secondary to interruption of the blood supply to the thoracolumbar spinal cord (9)(10)(11). Interlaminar ESIs have been associated with paraplegia secondary to the development of epidural hematomas (EDH) (12)(13)(14)(15). ...
... At this time, there is only one reported case of a foraminal hematoma following a transforaminal ESI and there was no chronic motor sequela (16). There have been multiple cases of EDH formation following interlaminar ESIs, but no case of paraplegia secondary to interruption of the blood supply to the spinal cord as these procedures do not endanger the arteries supplying the spinal cord (9)(10)(11)(12)(13)(14)(15)(16)(17). Of note, these cases report EDH formation following cervical, thoracic, and lumbar ESIs (9)(10)(11)(12)(13)(14)(15)(16)(17). ...
... There have been multiple cases of EDH formation following interlaminar ESIs, but no case of paraplegia secondary to interruption of the blood supply to the spinal cord as these procedures do not endanger the arteries supplying the spinal cord (9)(10)(11)(12)(13)(14)(15)(16)(17). Of note, these cases report EDH formation following cervical, thoracic, and lumbar ESIs (9)(10)(11)(12)(13)(14)(15)(16)(17). ...
Article
Background: Epidural hematoma (EDH) formation is one of the most feared complications associated with epidural steroid injections (ESI) as persons may experience permanent neurological deficits including paraplegia. The risk of developing an EDH following an ESI is expectedly increased in the context of concomitant anticoagulant and/or antiplatelet agent usage. While there exists significant evidence for the risks associated with anticoagulant and anti-platelet agents in epidural procedures, the anti-platelet effects of serotonin reuptake inhibitors medications (SRIs) in particular have received less attention. Case Report: A 70-year-old female with numerous cardiovascular comorbidities (on aspirin 81 mg daily for primary prevention of coronary artery disease) and fibromyalgia (on duloxetine 60 mg daily) underwent a fluoroscopically guided L3-L4 level interlaminar ESI for lumbar radiculopathy. Starting 6 hours post-procedure, the patient started to manifest severe back pain, bowel and bladder incontinence, and paraplegia. Magnetic resonance imaging (MRI) of the thoracic and lumbar revealed a large epidural fluid collection compressing the spinal cord and cauda equina. Unfortunately, a delay in care prevented the patient from receiving neurosurgical decompression. Conclusion: SRI associated coagulopathy may predispose to EDH formation by diminishing platelet aggregation. Therefore, weaning these medications, as dictated by the latest guidelines, should be highly considered, if possible and reasonable, to ensure favorable safety profiles for ESI procedures, especially in persons with multiple risk factors. Regardless of appropriate strategies to mitigate ESI associated bleeding risks, proceduralists should always maintain a healthy index of suspicion for EDH formation in the post-procedural phase as early diagnosis and intervention may prevent devastating neurological outcomes. Key words: Epidural hematoma, paraplegia, aspirin, duloxetine
... Consequently, it is expected that complications related to thoracic epidural injections are infrequent, specifi cally with formation of acute epidural hematoma after the procedures performed for chronic pain management. In fact, there have been only 2 published reports of thoracic epidural hematoma and related complications following epidural steroid injections (7,8). However, there are multiple reports of epidural hematoma in patients with paravertebral catheters (9,10) spontaneously without trauma (11)(12)(13)(14)(15), after shockwave lithotripsy (16), after spinal manipulative therapy (17), minor trauma (18), and spinal cord lead placement (19)(20)(21)(22)(23)(24). ...
... This appears to be the third case of acute epidural hematoma following epidural steroid injections in managing chronic spinal pain (7,8). The patient developed a thoracic epidural hematoma and required surgical intervention for decompression. ...
Article
While interlaminar and caudal epidural injections are frequently performed for chronic spinal pain, thoracic epidural injections are uncommon; constituting less than 5%. As a result, reports of complications related to thoracic epidural injections are rare including epidural hematoma leading to surgical decompression. Multiple strategies to prevent epidural hematoma in any region of the spine exist and include cessation of therapy with antithrombotics and anticoagulants, fi sh oil, and other drugs with a potential effect on coagulation. Thus far, multiple guidelines have recommended continuation of nonsteroidal antiinfl ammatory drugs (NSAIDs) and low dose aspirin. Some guidelines also have recommended continuation of antithrombotic therapy because of the increased risk of thromboembolic phenomenon in these patients. We report a case of thoracic epidural hematoma requiring surgical decompression without resultant residual dysfunction. It involves a thoracic epidural injection following which the patient developed left leg paresis over a 2-hour postinjection period. She was receiving low dose (81 mg) aspirin. She underwent surgical decompression with rapid recovery. This case report of acute thoracic epidural hematoma following interlaminar epidural steroid injection in a patient without antithrombotic therapy is rare, that could have been fatal without appropriate diagnosis and intervention. This case report shows that various commonly considered factors and precautions undertaken to avoid epidural hematoma formation are ineffective. This case report also illustrates the importance of prompt diagnosis, and emphasizes increasing levels of axial pain as most signifi cant features for the diagnosis. Key words: Interventional techniques, thoracic epidural injections, thoracic epidural hematoma, bleeding disorders, aspirin, antithrombotic agents, anticoagulants, nonsteroidal antiinfl ammatory drugs
... Thoracic epidural anesthesia was the most commonly used postoperative analgesia method in this population in the past [7]. But epidural hematoma, abscess, hemodynamic instability, and peripheral nerve lesions have restricted its application [8]. Video-assisted intercostal nerve cryoablation [9], continuous wound catheters delivering local anesthetic [10], bilateral thoracic paravertebral block [11], the erector spinae plane block [12], serratus anterior plane block (SAPB) [13], and pectoral nerve block [14] showed improvement in pain scores recently. ...
Article
Full-text available
Most patients undergoing the Nuss procedure reported moderate to severe pain after surgery. This study aimed to investigate the efficacy and safety of ultrasound-guided serratus anterior plane block (SAPB) combined with transversus thoracic muscle plane (TTMP) block for relieving acute pain in patients undergoing the Nuss procedure. The enrolled patients in our study were allocated to either receive combined nerve blocks with ropivacaine (NB group) or saline (CON group). The primary outcome of this study was postoperative pain at 2, 4, 8, 16, 24, 36, and 48 h during rest and movement (coughing). Secondary outcomes included intraoperative dosage of remifentanil, the time to extubation and the length of stay in the post-anesthesia care unit (PACU), the total acetaminophen and codeine tablet consumption, time to first bowel movement, time to first flatus, opioid-related adverse events, and the length of hospital stay. Patients in the NB group had significantly lower Numerical Rating Scale (NRS) pain scores compared with the CON group. The NB group required significantly less postoperative acetaminophen consumption and lower dosages of perioperative sufentanyl and remifentanil compared with the CON group. The length of stay in the PACU and time to extubation were significantly increased in the CON group compared with the NE group. Time to first bowel movement and time to first flatus were earlier in the NB group. But there were no significant differences between the groups in terms of the length of hospital stay and codeine tablet consumption. Ultrasound-guided SAPB and TTMP blocks in patients undergoing the Nuss procedure could provide effective analgesia. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000038506).
... Anticoagulation has been a major focus to try to explain the hematomas (3, [11][12][13][14]. However, despite meticulous attention to anticoagulation profiles, cervical hematomas have been reported, suggesting that anticoagulation is not the issue (15,16). Supporting the absence of a relationship between cervical epidural hematoma occurrence and anticoagulation is the report of Kaye et al (13) of 8 cases of hematomas after cervical epidurals in patients who were on no anticoagulant medications. ...
Article
Background: Epidural hematomas after appropriately performed cervicothoracic interlaminar epidural injections have been associated with the rapid onset of neurological symptoms and devastating outcomes, despite prompt identification and treatment. Anticoagulation issues were initially felt to be the problem, but the occurrence of fulminant hematomas in patients without coagulation forced a reassessment of the causes and responses to this problem. Objectives: To evaluate why fulminant epidural hematomas occur after cervicothoracic epidural injections, with a literature review to survey knowledge about them in the surgical literature, and to offer comments as to what the interventional pain physician can do to minimize their occurrence. Study design: A perspective piece with a literature review. Settings: Interventional pain management practices. Methods: A perspective on the issue of fulminant cervical hematomas and an associated literature review. Results: Anatomical studies show that there are no meaningful arteries in the posterior epidural spaces which would explain hematomas. There is a dense posterior intravertebral epidural venous plexus at C1 and also at C6-C7 extending caudally to the upper thoracic region. A venous origin has been questioned because venous pressure was felt to be too low to explain the bleeding. The surgical literature, going back 80 years, contains numerous reports of engorged epidural veins causing radiculopathy and myelopathy. These engorged veins can occur in the presence or absence of spinal pathology. There is no known means of reliably identifying these engorged veins; they have been mistaken for disc protrusions. At least one report documents massive bleeding from these veins. Studies done on a feline model of cervical stenosis suggest that the epidural pressure can reach arterial levels. Limitations: No direct documentation of arterialized posterior intravertebral epidural venous pressures has been made. While anatomical anomalies and degeneration contribute to epidural scarring, we do not have a full understanding as to the cause of arterialization of veins, particularly in younger patients with no obvious intraspinal pathology. Conclusion: Fulminant cervicothoracic epidural hematomas after an epidural injection appear to arise from the unintentional and unavoidable puncture of arterialized veins with sharp needles. A technique to open a path out from the foramen so that the blood can escape is described. Alternatively, providers should consider injecting more cephalad, between C2-C3 and C6-C7 in the cervical spine, or an alternative procedure, such as a selective nerve root injection. A cervical transforaminal approach should only be attempted with a blunt needle, which cannot enter an artery. Should symptoms occur, cervical flexion rotation maneuvers should be implemented while awaiting prompt transfer to a facility where an appropriate diagnosis and treatment can be provided. Key words: Cervical epidural hematoma, cervical epidural injection, posterior intravertebral venous plexus, arterialized epidural veins, pressurized epidural veins.
... Spinal epidural hematomas are exceedingly rare complications with potentially devastating long-term consequences. Previous case reports detailing spinal epidural hematomas in patients receiving epidural steroid injections often involve injecting patients who are either on anticoagulants or have spinal stenosis (6)(7)(8)(9). Generally, anticoagulants (such as warfarin) are discontinued in patients prior to the epidural steroid injection and normal international normalized ratio verified as advocated by the American Society of Regional Anesthesia and Pain Medicine and the American Society of Interventional Pain Physicians (4,5). ...
Article
Epidural steroid injections are interventional pain procedures often used to treat lumbar radicular pain. The most serious complication of this procedure is the formation of a spinal epidural hematoma, which can result in profound permanent neurologic deficits if left untreated. A 76-year-old woman with mild lumbar spinal stenosis (L4-L5, L5-S1) and lumbar dextroscoliosis, previously on 81mg of aspirin daily (discontinued at 14 days prior to procedure) and not on anticoagulation therapy, underwent a lumbar epidural steroid injection (T12-L1). Post-procedurally, she developed bilateral leg paralysis. A magnetic resonance imaging (MRI) study revealed a fluid collection concerning for hematoma. Neurosurgery was consulted, but at the time of evaluation, she had near resolution of her presenting symptoms and the decision was made to monitor her for 48 hours. Three months after discharge, MRI revealed no persistent symptoms or radiographic evidence of sequelae from epidural hematoma. The frequency of spinal epidural hematomas after epidural steroid injections is unknown. This patient did not have traditional risk factors of severe spinal stenosis or the use of anticoagulant or antiplatelet agents. A radiographic fluid collection was seen, which may represent blood or persistent injectate. A formal surgical diagnosis was not obtained, as her symptoms spontaneously improved without further need for intervention. We report the first case of presumed persistent injectate compression of the lumbar spinal cord, resulting in bilateral lower extremity weakness in a patient with dextroscoliosis, mimicking spinal epidural hematoma with spontaneous resolution without intervention. Key words: Epidural steroid injection, spinal epidural hematoma, dextroscoliosis, lumbar radiculopathy, spinal stenosis, lower extremity paralysis
... New challenges arise when practitioners perform interventional procedures on patients who are anticoagulated. Even with adherence to guidelines for performing neuroaxial injections in the setting of anticoagulants, patients may develop an epidural hematoma and paraplegia after thoracic epidural steroid injection 32 . Combination of LAs and steroids improves postoperative analgesia. ...
Article
Full-text available
The objective of this clinical update, based on recently published literature, was to discuss incidence and characteristics of the most relevant clinical adverse effects associated with local anesthetic and steroid use in regional anesthesia and treatment of acute or chronic pain. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from 2015 to 2018 was performed. This narrative review provides anesthesia practitioners with updated evidences on complications and contraindications of local anesthetic and steroid use with emphasis on current points of view regarding prevention, early diagnosis and treatment of adverse events.
... One case report described an epidural hematoma resulting in paraplegia after image-guided thoracic interlaminar corticosteroid injection [30]. The patient had stopped warfarin for seven days and was bridged with enoxaparin 1 mg/kg twice daily, which was discontinued 24 hours prior to the procedure. ...
Article
Full-text available
Objective: To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pain. Design: Systematic review of the literature with comprehensive analysis of the published data. Interventions: Following a search of the literature for studies pertaining to spine pain interventions in patients on anticoagulant medication, seven reviewers appraised the studies identified and assessed the quality of evidence presented. Outcome measures: Evidence was sought regarding risks associated with either continuing or ceasing anticoagulant and antiplatelet medication in patients having image-guided interventional spine procedures. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system. Results: From a source of 120 potentially relevant articles, 14 provided applicable evidence. Procedures involving interlaminar access carry a nonzero risk of hemorrhagic complications, regardless of whether anticoagulants are ceased or continued. For other procedures, hemorrhagic complications have not been reported, and case series indicate that they are safe when performed in patients who continue anticoagulants. Three articles reported the adverse effects of ceasing anticoagulants, with serious consequences, including death. Conclusions: Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.
Chapter
The prevalence of mid- and upper-back chronic pain is significantly lower than low back and neck pain with reports showing pain of thoracic origin in 5–15% of the patients, compared to 24–44% with neck pain and 33–56% with low back pain. Thoracic intervertebral discs, nerve roots, and facet joints are capable of transmitting pain in the thoracic spine with radiation into the chest wall and abdominal wall. Chronic, persistent thoracic and chest wall pain and radicular pain may be secondary to disc herniation, discogenic pain, spinal stenosis, or post-thoracic surgery syndrome. Epidural injections are one of the commonly utilized treatment modalities for managing chronic thoracic pain administered by either interlaminar approach or transforaminal approach. There is significant paucity of literature concerning thoracic epidural injections in managing chronic pain, with only one high-quality randomized controlled trial (RCT), leading to Level II evidence for thoracic interlaminar epidural injections with no evidence available for thoracic transforaminal epidural injections.
Article
Intro: Pain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population. Methods: Pediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol. Results: Forty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain. Conclusion: Post-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum. Level of evidence: Level II.
Chapter
An epidural steroid injection is a minimally invasive and effective procedure frequently used for several conditions such as thoracic disc herniation, radiculopathy, spinal stenosis, postlaminectomy syndrome, and cancer pain. Corticosteroids diminish inflammation, suppress neuronal discharge, and desensitize dorsal horn neurons. Thoracic interlaminar procedures are more prone to complications compared to the lumbar region due to anatomic differences. Intravascular injection is a common issue that may be faced during epidural injections. Intravascular contrast agent spreads like a thin line or curvilinearly while it disappears during the injection. Dural puncture is a common complication of epidural injections with an incidence up to 5%. The incidence of neurologic complications after neuraxial blockade is higher in patients who have pre‐existing spinal stenosis. Patients under a long‐term anticoagulation medication are at high risk of hemorrhagic complications. Early surgical drainage is recommended to avoid neurologic injury and other complications.
Article
Résumé Les infiltrations rachidiennes à l’étage thoracique et cervical sont nettement moins fréquemment pratiquées qu’à l’étage lombaire. Avant de les envisager, une évaluation clinique et paraclinique avec des images pouvant détecter des lésions inflammatoires doit être conduite. À l’étage thoracique, des infiltrations des articulations costo-transversaires ou costo-vertébrales ou des articulaires postérieures (ou interapophysaires postérieures ou zygapohysaires) uni ou bilatérales peuvent être réalisées. La concordance anatomo-clinique peut être obtenue au mieux par la réalisation de blocs anesthésiques. S’agissant d’infiltration articulaire, un corticoïde particulaire (acétate de prednisolone) ou non particulaire (dexaméthasone) peut être utilisé. Les infiltrations épidurales à l’étage thoracique n’ont pas d’indication rhumatologique. À l’étage cervical, dans notre opinion, les infiltrations épidurales et foraminales ne doivent pas être pratiquées du fait du risque de complications en partie liées aux voies d’abord elles-mêmes et aux conditions anatomiques locales et de l’absence de supériorité démontrée de ces voies sur l’injection articulaire postérieure, tandis que les sociétés savantes françaises d’imagerie médicale ont conservé des indications sous réserve de n’utiliser qu’un corticoïde non particulaire (dexaméthasone). Les infiltrations des articulaires postérieures à l’étage cervical doivent être réservées aux cas de névralgies cervicobrachiales résistants au traitement médical, sélectionnés en Réunion de Concertation Pluridisciplinaire après s’être assuré que l’injection peut être faite à distance d’un étage opéré et qu’il n’y a pas sur une IRM de grosses veines en regard du massif articulaire où l’on projette de faire l’injection. Les infiltrations de l’articulation dans la zone de la charnière cervico-occipitale (notamment de l’articulation latérale C1-C2 ou à son regard) doivent être précédées d’une décision en Réunion de Concertation Pluridisciplinaire et le patient doit être informé des risques potentiels d’accident neurologiques graves.
Article
A 71-year-old woman on aspirin presented for a distal pancreatectomy, splenectomy, and partial colectomy with a T8/9 epidural catheter placed preoperatively in 3 attempts. Prophylactic 5000 units of subcutaneous heparin were given before the procedure. After catheter removal on postoperative day 2, the patient developed transient bilateral lower extremity paralysis, with near complete recovery within 30 minutes. An urgent MRI revealed a T4-T8 epidural hematoma prompting an emergent T3-T8 laminectomy. This case presentation highlights the need for heightened awareness regarding complications related to neuraxial analgesia in patients receiving unfractionated heparin for thromboembolism prophylaxis with concurrent aspirin use.
Article
Full-text available
The widespread use of central neuraxial block (CNB) and the prevalence of anticoagulation for different indications have led to an inevitable overlap between the two. The most serious complication of CNB in anticoagulated patients is the risk of spinal/epidural haematoma. Performing CNB in these patients is a complex decision that should take into account the twin risks of bleeding and venous/arterial thrombosis if anticoagulation therapies were to be stopped. Various guidelines have been issued to achieve normal haemostasis and thus allow safe administration of CNB. However, the evidence base for many such recommendations is weak, relying mainly on case reports, small studies and pharmacokinetics of the drugs. Given these limitations it is crucial to fully assess individual risk factors and understand anticoagulant pharmacokinetics in order to appropriately set time intervals for catheter insertion/removal. This paper will review traditional and newer anticoagulation/antiplatelet therapies with a view to improving the management of anticoagulated patients undergoing CNB.
Article
Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures.In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine.The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.
Article
Background: Reports of prevalence of spinal pain indicate the prevalence of thoracic pain in approximately 13% of the general population compared to 32% of the population with neck pain and 43% of the population with low back pain during the past year. Even though, thoracic pain is less common than neck or low back pain, the degree of disability resulting from thoracic pain disorders seems to be similar to other painful conditions. Interventions in managing chronic thoracic pain are also less frequent, leading to the paucity of literature about various interventions in managing chronic thoracic pain. Thoracic intervertebral discs and thoracic facet joints have been shown to be pain generators, even though thoracic radicular pain is very infrequent. Thoracic epidural injections are one of the commonly performed procedures in managing thoracic pain. The efficacy of thoracic epidural injections has not been well studied. Study design: A randomized, double-blind, active controlled trial. Setting: Private interventional pain management practice and specialty referral center in the United States. Objective: The primary objective was to assess the effectiveness of thoracic interlaminar epidural injections in providing effective pain relief and improving function in patients with chronic mid and/or upper back pain. Methods: One hundred and ten patients were randomly assigned into 2 groups with 55 patients in each group receiving either local anesthetic alone (Group I) or local anesthetic with steroids (Group II). Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes assessment: Outcomes were assessed utilizing Numeric Rating Scale (NRS), the Oswestry Disability Index (ODI) 2.0, employment status, and opioid intake. The patients experiencing greater than 3 weeks of significant improvement with the first 2 procedures were considered as successful. Others were considered as failed participants. Significant improvement was defined as a decrease of greater than 50% NRS scores and ODI scores with measurements performed at baseline, 3, 6, 12, 18, and 24 months post treatment. Results: Significant improvement was seen in 71% in Group I and 80% in Group II at the end of 2 years with all participants; however, improvement was seen in 80% and 86% when only successful patients were considered. Therapeutic procedural characteristics showed 5 to 6 procedures per 2 years with total average relief of 80 weeks in Group I and 78 weeks in Group II in the successful patient category; whereas, it was 71 and 72 weeks when all patients were considered. Limitations: Limitations of this assessment include lack of a placebo group. Conclusions: Based on the results of this trial, it is concluded that chronic thoracic pain of non-facet joint origin may be managed conservatively with thoracic interlaminar epidural injections with or without steroids.
Article
Postoperative epidural analgesia is effective and widely utilised after major abdominal surgery. Spinal haematoma is a rare and devastating complication after epidural analgesia. Well-established risk factors for the development of spinal haematoma after neuraxial procedures have been documented. We present the case of a patient with normal pre-operative coagulation parameters who developed a spinal haematoma more than 24 h after removal of an epidural catheter; she had been without oral intake for only 4 days during which time she developed vitamin K-deficient coagulopathy. Clinicians should consider pre-operative screening of coagulation (International Normalised Ratio), or giving vitamin K supplementation, before performing neuraxial procedures in patients who are at risk of developing vitamin K deficiency or coagulopathy in the peri-operative period.
Article
Reports from the United States Government Accountability Office (GAO), the Institute of Medicine (IOM), the Medicare Payment Advisory Commission (MedPAC), and the Office of Inspector General (OIG) continue to express significant concern with the overall fiscal sustainability of Medicare and the exponential increase in costs for chronic pain management. The study is an analysis of the growth of interventional techniques in managing chronic pain in Medicare beneficiaries from 2000 to 2011. To evaluate the use of all interventional techniques in chronic pain management. The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master Data from 2000 to 2011. Interventional techniques for chronic pain have increased dramatically from 2000 to 2011. Overall, the increase of interventional pain management (IPM) procedures from 2000 to 2011 went up 228%, with 177% per 100,000 Medicare beneficiaries. The increases were highest for facet joint interventions and sacroiliac joint blocks with a total increase of 386% and 310% per 100,000 Medicare beneficiaries, followed by 168% and 127% for epidural and adhesiolysis procedures, 150% and 111% for other types of nerve blocks and finally, 28% and 8% increases for percutaneous disc procedures. The geometric average of annual increases was 9.7% overall with 13.7% for facet joint interventions and sacroiliac joint blocks and 7.7% for epidural and adhesiolysis procedures. The limitations of this study included a lack of inclusion of Medicare participants in Medicare Advantage plans, as well as potential documentation, coding, and billing errors. Interventional techniques increased significantly in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 177% in the utilization of IPM services per 100,000 Medicare beneficiaries, with an annual geometric average increase of 9.7%. The study also showed an exponential increase in facet joint interventions and sacroiliac joint blocks.
Article
Background. Neurological deficits after epidural steroid injection (ESI) are rare but occur despite meticulous technique. Some neurologic deficits reverse spontaneously, others reverse only with timely interventions, and some are permanent. Etiologies vary. Objectives. Assess the immediate diagnostic and treatment steps to undertake when a patient experiences a severe neurologic deficit so that the best neurologic recovery can be obtained. Design. The literature was systematically reviewed for case reports and case series describing neurologic deficit after ESI. Outcome Measures. From these reports, the mechanism, temporal onset, permanence or reversibility of the deficit, and assessment and management were recorded and analyzed. Results. Thirty-three cases of neurological deficits were identified: 19 permanent deficits and 14 reversible. Infarction was significantly associated with permanent deficits (P ≤ 0.008) and presented just after injection (P ≤ 0.03), compared with “noninfarct” groups. Temporal onset of differential diagnoses (subdural and intrathecal injection, hematoma, and vascular punctures) overlap. When deficits did not resolve consistent with inadvertent subdural/intrathecal injection, timely initial magnetic resonance imaging (MRI) should be carried out to diagnose mass lesions, which have an optimal 8-hour window for effective surgical intervention. Mass lesions have an excellent prognosis for recovery (83%) compared with infarctions (9%) (P ≤ 0.005). Conclusions. Faced with deficits after ESI that do not resolve, the physician will need access to MRI, or similar radiographic studies, and subsequent neurosurgical consultation and facilities if MRI results indicate a decompressible lesion. Respiratory insufficiency with quadriplegia and loss of consciousness can occur, and in the worst of scenarios, the physician would also need the capability to ventilate the patient.
Article
Background: In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. Methods: Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. Results: Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10(-5) (95% confidence interval [CI], 4.5 × 10(-5) to 23.1 × 10(-5)). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10(-5)). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). Conclusions: In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.
Article
M ultiple randomized clinical trials have established the efficacy of standard heparin (SH) anticoagulation for venous thromboembolism prophylaxis. However, for high-risk populations, such as patients undergoing total hip or knee replacement, SH is relatively ineffective and may be associated with significant bleeding complications (1). Initial animal model studies suggested that low molecular weight fractions of heparin, when administered at equivalent antithrombotic doses, caused less bleeding than SH (2). These early studies raised the exciting possibility of separating the antithrombotic from the bleeding effects of heparin. The efficacy and safety of low molecular weight heparins (LMWH) as postoperative ve-nous thromboembolism prophylaxis subsequently has been demonstrated in more than 60 clinical trials including more than 20,000 patients (3). However, reports of spinal hematoma occurring spontaneously and in association with regional anesthesia (4,5) have generated concern regarding the safety of spinal or epidural anesthesia in patients receiving LMWH. In this review, we focus on the biochemistry and phar-macology of LMWH compared with SH, current LMWH prophylaxis regimens, and the implications of perioperative LMWH prophylaxis for anesthesia, particularly among patients receiving regional anesthesia and analgesia. Guidelines will be provided for minimizing the risk of spinal hematoma in patients undergoing regional anesthesia while receiving periopera-tive anticoagulant-based prophylaxis.
Article
Anesthesiologists often encounter anticoagulated patients in two clinical settings: patients with medical conditions requiring chronic anticoagulation and patients receiving perioperative thromboembolism prophylaxis. In the United Slates, warfarin is the most commonly used oral anticoagulant and is the focus of this study. The use of neuraxial block in patients receiving warfarin, either chronically or for perioperative thromboembolism prophylaxis, is nor a new issue. Although the preponderance of evidence suggests that as a specialty we have learned to safely practice regional anesthesia in these patient populations, we seek to emphasize the unknown. The actual incidence of complications from combining neuraxial blocks with warfarin therapy is unknown. We believe the numerator, the number of complications associated with neuraxial block and warfarin therapy, is probably underreported. The denominator, the number of neuraxial blocks placed in patients receiving or recently discontinued from warfarin therapy, is probably high but not well documented. This report will focus on the pharmacology of warfarin, how its anticoagulant effect is measured, and how that impacts the practice of regional anesthesia and analgesia.
Article
Spinal hematoma has been described in autopsies since 1682 and as a clinical diagnosis since 1867. It is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated. Some cases of subarachnoid spinal hematoma may present with symptoms similar to those of cerebral hemorrhage. The literature offers no reliable estimates of the incidence of spinal hematoma, perhaps due to the rarity of this disorder. In the present work, 613 case studies published between 1826 and 1996 have been evaluated, which represents the largest review on this topic to date. Most cases of spinal hematoma have a multifactorial etiology whose individual components are not all understood in detail. In up to a third of cases (29.7%) of spinal hematoma, no etiological factor can be identified as the cause of the bleeding. Following idiopathic spinal hematoma, cases related to anticoagulant therapy and vascular malformations represent the second and third most common categories. Spinal and epidural anesthetic procedures in combination with anticoagulant therapy represent the fifth most common etiological group and spinal and epidural anesthetic procedures alone represent the tenth most common cause of spinal hematoma. Anticoagulant therapy alone probably does not trigger spinal hemorrhage. It is likely that there must additionally be a "locus minoris resistentiae" together with increased pressure in the interior vertebral venous plexus in order to cause spinal hemorrhage. The latter two factors are thought to be sufficient to cause spontaneous spinal hematoma. Physicians should require strict indications for the use of spinal anesthetic procedures in patients receiving anticoagulant therapy, even if the incidence of spinal hematoma following this combination is low. If spinal anesthetic procedures are performed before, during, or after anticoagulant treatment, close monitoring of the neurological status of the patient is warranted. Time limits regarding the use of anticoagulant therapy before or after spinal anesthetic procedures have been proposed and are thought to be safe for patients. Investigation of the coagulation status alone does not necessarily provide an accurate estimate of the risk of hemorrhage. The most important measure for recognizing patients at high risk is a thorough clinical history. Most spinal hematomas are localized dorsally to the spinal cord at the level of the cervicothoracic and thoracolumbar regions. Subarachnoid hematomas can extend along the entire length of the subarachnoid space. Epidural and subdural spinal hematoma present with intense, knife-like pain at the location of the hemorrhage ("coup de poignard") that may be followed in some cases by a pain-free interval of minutes to days, after which there is progressive paralysis below the affected spinal level. Subarachnoid hematoma can be associated with meningitis symptoms, disturbances of consciousness, and epileptic seizures and is often misdiagnosed as cerebral hemorrhage based on these symptoms. Most patients are between 55 and 70 years old. Of all patients with spinal hemorrhage, 63.9% are men. The examination of first choice is magnetic resonance imaging. The treatment of choice is surgical decompression. Of the patients investigated in the present work, 39.6% experienced complete recovery. The less severe the preoperative symptoms are and the more quickly surgical decompression can be performed, the better are the chances for complete recovery. It is therefore essential to recognize the relatively typical clinical presentation of spinal hematoma in a timely manner to allow correct diagnostic and therapeutic measures to be taken to maximize the patient's chance of complete recovery. Electronic Supplementary Material is available if you access this article at http://dx.doi.org/10.1007/s10143-002-0224-y. On that page (frame on the left side), a link takes you directly to the supplementary material.