British Journal of Neurosurgery, April 2015; 29(2): 280 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.957652
Rapidly progressive quadriparesis secondary to cervical epidural hematoma – A rare complication of epidural injection Lee A. Tan, Manish K. Kasliwal & Harel Deutsch
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
incidence of 0.4–13.8 cases per 100,000 patients.1 However, the incidence of SEH as a complication of ESI has not being defined, with only a few case reports in existing literature.1–5 The known risk factors for SEH associated with ESI include the use of warfarin, heparin, low molecular weight heparin, as well as antiplatelet agents.1,5 This case highlights the fact that even with prior laminectomies, SEH can be a complication of cervical ESI and cause rapidly progressive quadriparesis. Despite having prior laminectomies, the blood can accumulate between the dura and scar tissue, resulting in cervical spinal cord compression and quadriparesis. Furthermore, the evidence on ESI for neck pain is limited; a recent meta-analysis revealed the lack of Class I evidence supporting the use of epidural injection in treating chronic axial neck pain.6 Therefore, ESI in patients with known coagulopathy or antiplatelet agents should be avoided given the rare, but devastating clinical sequelae as demonstrated in this patient.
A 64-year-old man presented with rapidly progressive quadriparesis one day after receiving cervical epidural steroid injection (ESI) for chronic neck pain. He was taking daily aspirin and clopidogrel due to a history of cardiac stent placement with questionable restenosis. He had C3–6 laminectomies four years ago at an outside institution for symptomatic myeloradiculopathy consisted of severe right arm pain, moderate neck pain, and mild gait instability. His neck pain did not improve after surgery, which prompted the cervical ESI. Emergent magnetic resonance imaging (MRI) (Fig. 1) demonstrated severe spinal cord compression at C4–5 by an epidural mass consistent with cervical epidural hematoma centered at the epidural injection site. The patient was taken to the operating room under emergency for cervical epidural hematoma evacuation. Intraoperatively, a large cervical epidural hematoma was visualized between scar tissues from prior laminectomies and the thecal sac. Spinal epidural hematoma (SEH) is a rare complication associated with epidural catheterizations with an estimated
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Chien GCC, McCormick Z, Araujo M, Candido KD. The potential contributing effect of ketorolac and fluoxetine to a spinal epidural hematoma following a cervical interlaminar epidural steroid injection: a case report and narrative review. Pain Physician 2014;17: E385–95. 2. Jusué-Torres I, Ortega-Zufiria JM, Tamarit-Degenhardt M, et al. [Iatrogenic cervical epidural hematoma: case report and review of the literature]. Neurocir Astur Spain 2011;22:332–6. 3. LaBan MM, Kasturi G, Wang I-M. Epidural corticosteroid injections precipitating epidural hematomas with spinal paresis. Am J Phys Med Rehabil Assoc Acad Physiatr 2007;86:166–7. 4. Lee JY, Nassr A , Ponnappan RK. Epidural hematoma causing paraplegia after a fluoroscopically guided cervical nerve-root injection. A case report. J Bone Joint Surg Am 2007;89:2037–9. 5. Xu R, Bydon M, Gokaslan ZL, et al. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009;11:358–64. 6. Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician 2012;15: E405–34.
Fig. 1. T2-weighted MRI (sagittal view) demonstrating severe spinal cord compression from spinal epidural hematoma at C4–5.
Correspondence: Lee A. Tan, MD, Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 30 June 2014; accepted 19 August 2014
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Rapidly progressive quadriparesis secondary to cervical epidural hematoma – A rare complication of epidural injection Lee A. Tan, Manish K. Kasliwal & Harel Deutsch
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
incidence of 0.4–13.8 cases per 100,000 patients.1 However, the incidence of SEH as a complication of ESI has not being defined, with only a few case reports in existing literature.1–5 The known risk factors for SEH associated with ESI include the use of warfarin, heparin, low molecular weight heparin, as well as antiplatelet agents.1,5 This case highlights the fact that even with prior laminectomies, SEH can be a complication of cervical ESI and cause rapidly progressive quadriparesis. Despite having prior laminectomies, the blood can accumulate between the dura and scar tissue, resulting in cervical spinal cord compression and quadriparesis. Furthermore, the evidence on ESI for neck pain is limited; a recent meta-analysis revealed the lack of Class I evidence supporting the use of epidural injection in treating chronic axial neck pain.6 Therefore, ESI in patients with known coagulopathy or antiplatelet agents should be avoided given the rare, but devastating clinical sequelae as demonstrated in this patient.
A 64-year-old man presented with rapidly progressive quadriparesis one day after receiving cervical epidural steroid injection (ESI) for chronic neck pain. He was taking daily aspirin and clopidogrel due to a history of cardiac stent placement with questionable restenosis. He had C3–6 laminectomies four years ago at an outside institution for symptomatic myeloradiculopathy consisted of severe right arm pain, moderate neck pain, and mild gait instability. His neck pain did not improve after surgery, which prompted the cervical ESI. Emergent magnetic resonance imaging (MRI) (Fig. 1) demonstrated severe spinal cord compression at C4–5 by an epidural mass consistent with cervical epidural hematoma centered at the epidural injection site. The patient was taken to the operating room under emergency for cervical epidural hematoma evacuation. Intraoperatively, a large cervical epidural hematoma was visualized between scar tissues from prior laminectomies and the thecal sac. Spinal epidural hematoma (SEH) is a rare complication associated with epidural catheterizations with an estimated
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Chien GCC, McCormick Z, Araujo M, Candido KD. The potential contributing effect of ketorolac and fluoxetine to a spinal epidural hematoma following a cervical interlaminar epidural steroid injection: a case report and narrative review. Pain Physician 2014;17: E385–95. 2. Jusué-Torres I, Ortega-Zufiria JM, Tamarit-Degenhardt M, et al. [Iatrogenic cervical epidural hematoma: case report and review of the literature]. Neurocir Astur Spain 2011;22:332–6. 3. LaBan MM, Kasturi G, Wang I-M. Epidural corticosteroid injections precipitating epidural hematomas with spinal paresis. Am J Phys Med Rehabil Assoc Acad Physiatr 2007;86:166–7. 4. Lee JY, Nassr A , Ponnappan RK. Epidural hematoma causing paraplegia after a fluoroscopically guided cervical nerve-root injection. A case report. J Bone Joint Surg Am 2007;89:2037–9. 5. Xu R, Bydon M, Gokaslan ZL, et al. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009;11:358–64. 6. Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician 2012;15: E405–34.
Fig. 1. T2-weighted MRI (sagittal view) demonstrating severe spinal cord compression from spinal epidural hematoma at C4–5.
Correspondence: Lee A. Tan, MD, Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St. Suite 855, Chicago, IL 60612, USA. Tel: ⫹ 312-942-6644. Fax: ⫹ 312-563-3358. E-mail: [email protected] Received for publication 30 June 2014; accepted 19 August 2014
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