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

Case report

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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.

Article Information

Address correspondence to: Ali Bydon, M.D., Department of Neurosurgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 7-109, Baltimore, Maryland 21287. email: abydon1@jhmi.edu.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Sagittal MR images of the lumbosacral spine. A T2-weighted image (left) and STIR image (right) showing an EDH causing massive compression of the thecal sac in the L2–4 spinal levels.

  • View in gallery

    Lumbosacral spine MR images. The T2-weighted axial images above the level of the compression (left) and through the level of maximal compression (right) show complete obliteration of the CSF and massive compression of the thecal sac and cauda equine.

  • View in gallery

    Sagittal (left) and axial (right) T2-weighted MR images showing evacuation of hematoma and thecal sac decompression with restoration of CSF flow around previously compressed nerve roots.


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