Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines

Case report

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  • 1 Department of Neurosurgery and
  • | 2 Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

Abbreviations used in this paper:

ASRA = American Society for Regional Anesthesia and Pain Medicine; EDH = epidural hematoma; LMW = low-molecular-weight.

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