|Year : 2015 | Volume
| Issue : 2 | Page : 111-114
Cervical epidural hematoma: Following interlaminar cervical epidural steroid injection
Dwarkadas Kanhayalal Baheti1, Vaibhavi Baxi2, Prakash Gawankar2, Vinay Chauhan3, Sanjeev Mehta4, Rajan Shah5
1 Department of Pain, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Anaesthesiology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
3 Department of Neurology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
4 Department of Chest Physician, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
5 Department of Neurosurgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||15-Apr-2015|
Dr. Dwarkadas Kanhayalal Baheti
Lilavati Hospital and Research Centre, Bandra-West, Mumbai - 400 050, Maharashtra
Source of Support: None, Conflict of Interest: None
Cervical epidural steroid injection is a common procedure performed for patients with cervical radiculopathy. Cervical epidural hematoma is a rare but known complication of Intervention Pain Treatment Procedure (IPTP) in healthy patients without coagulopathy. We report a case of cervical epidural hematoma as a complication of cervical epidural steroid injection in an elderly patient with cervical radiculopathy; resulting in right upper limb motor sensory deficit. Patient responded to conservative management and surgery was not performed since symptoms progressively improved.
Keywords: Cervical epidural steroid injection, cervical radiculopathy, complication, epidural hematoma, interventional pain treatment procedures (IPTPs), multimodal approach
|How to cite this article:|
Baheti DK, Baxi V, Gawankar P, Chauhan V, Mehta S, Shah R. Cervical epidural hematoma: Following interlaminar cervical epidural steroid injection. Indian J Pain 2015;29:111-4
|How to cite this URL:|
Baheti DK, Baxi V, Gawankar P, Chauhan V, Mehta S, Shah R. Cervical epidural hematoma: Following interlaminar cervical epidural steroid injection. Indian J Pain [serial online] 2015 [cited 2020 May 27];29:111-4. Available from: http://www.indianjpain.org/text.asp?2015/29/2/111/155183
| Introduction|| |
The relief of pain is a basic human right and chronic pain too is a health care issue. The practice of pain medicine is characterized by multimodal treatment incorporating medical, psychological, physical, and Interventional Pain Treatment Procedure (IPTPs). A complication is an unwarranted outcome which develop as a result of treatment modality either with medications alone or with IPTP. 
In multi modal approach the Interventional pain treatment procedure is effective modality for relief of chronic pain due to cervical radiculopathy. Cervical epidural steroid injection under fluoroscopy is an accepted IPTP for patients with cervical radiculopathy. The reports of complications with cervical epidural steroid injection are rare, and most of these are fairly benign. Manchikanti et al.,  reported hematoma in closed spaces like the epidural space, can cause nerve compression; the incidence of which is reported as 4.1% for cervical epidurals.
It is important to acknowledge that spinal epidural hematomas can occur after cervical epidural injection, and prompt recognition and treatment could improve the prognosis for recovery. Tam et al.,  reported a case of a spinal-epidural hematoma occurred after a combined spinal-epidural anesthetic inspite of stopping of clopidroge for 7 days and administration of dalteparin for 7 days.
We report a case of cervical epidural hematoma following cervical epidural steroid injection for an elderly patient with cervical radiculopathy and timely conservative treatment resulted in almost complete recovery of symptoms.
| Case Report|| |
CK 84-years-old lady presented with the complaints of pain (VAS 8/10) in the neck radiating down to both shoulders with tingling sensations in right upper limb with restricted movements shoulder and right upper limb. On clinical examination there was tenderness in the neck and right shoulder. The neurological examination was within normal limits. The MRI of cervical spine documented disc bulges at C2-3, C3-4 and C4-5 levels with left foraminal narrowing at C3-4 level and nerve impingement. She was diagnosed with cervical radiculopathy and an interlaminar cervical epidural steroid injection with right suprascalupar block was planned under local anesthesia.
She was a known case of hypertension, bronchial asthma and was under regular treatment for the same. She was not on any antiplatelet drugs and coagulation profile was within normal limits.
As precautionary measure she was put of intravenous (IV) steroid and regular inhaler day before and morning of procedure.
After securing an IV line and monitoring, prone position was given. Under fluoroscopic control 18 gauge Tuoghy needle was directed towards seventh cervical epidural space with hanging drop technique. The negative aspiration for blood or CSF was confirmed the epidural space. Injection Omnipaque 0.5 cc was injected after negative aspiration. Now Injection Aurocort (preservative free Triamcenalone Acetonide) 40 mg with 0.5 ml saline was injected into the epidural space. At the end of injection patient suddenly moved her neck, probably be due to pain or bronchospasm. She had sudden vasovagal attack with bradycardia and bronchospasm which was treated with Inj. Atropine sulphate 0.6 mg. She was promptly made supine and kept in propped up position. On auscultation there was bilateral wheeze treated with Injection Hydrocortisone 100 mg, nebulization with salbutamol and budecort with 100% oxygen. All vital parameters were stable.
Now she complained of numbness and inability to move the right upper limb. However touch sensation was preserved.
A full neurological assessment by neurologist revealed weakness and numbness in the right upper limb with no other changes. A magnetic resonance imaging (MRI) scan was performed within 3 hours of patient's symptoms and revealed a localized hypointense lesion from C7-T1 region likely to be a hematoma and cord edema [Figure 1] and [Figure 2].
A neurosurgical opinion was sought in and it was decided to go ahead with conservative management as no surgical intervention was required.
Immediately physiotherapy for right upper limb was started and pt. was given IV.
Methylprednisolone for five days. The patient on discharge showed improvement with power to grade 3+ and residual sensory parasthesia. A repeat MRI was advised to confirm resolution of the hematoma however the patient was reluctant and refused to do so.
She continued with physiotherapy, neuropathic and other pain medications for four weeks which resulted in pain free upper limb movements and significant reduction in tingling sensation.
| Discussion|| |
The complications are divided into three categories such as 1-pharmacological or medications related; 2-Interventional Pain treatment procedure related; 3-Implant or equipment related. 
The complications due to IPTP can further be divided into actual procedure or injected drug-related. The procedure related complications are such as vasovagal reactions, backache, nerve injury, vessel injury, other tissue injury, dural puncture, pulmonary, or neurological trauma, and Infection. The injected drug such as epidural steroid with or without preservative, hypertonic saline, dye ionic or non ionic dye, local anaesthetic or neurolytic agent due to their volume may result in rise in epidural, ocular and intracerebral pressure. 
It is commonly accepted that cervical epidural procedures have risks, although the general perception is that their incidence is low. The approach to cervical epidural can be inter laminar or trans foraminal depending upon individual preference and same is true with technique either loss of resistance or hanging drop technique.
Cervical radiculitis affects approximately 83 per 100,000 populations per year  and most common causes of cervical radiculitis are herniated disk (21.9%) and spondylosis (68.4%). The majority of those affected do not undergo surgery. The outcomes are favourable in both surgical and non-surgically treated groups without reproducible significant outcome differences of one treatment over the other. 
Iatrogenic epidural hematoma following spinal puncture incidence is 0.02%. The role of surgical intervention for decompression is progressive myelopathy with a radiological evidence of cord compression from the epidural hematoma. However in majority of the patients with partial non disabiling deficit the conservative management is accepted mode of therapy with good results.
In our patient she had only root deficit without any myelopathy, also there was no significant mass effect on the cord noted from the epidural hematoma, thus was managed conservatively.
The complications reported with interlaminar cervical epidural steroid injections include dural puncture, bloating, nausea and vomiting, vasovagal reaction, facial flushing, fever, nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, stiff neck, Cushing's syndrome, transient paresthesias, hypotension, respiratory insufficiency, transient blindness, epidural abscess, paralysis, cord injury, and death.  Spinal epidural hematoma is a rare complication of pain control procedure and is also an uncommon cause of acute myelopathy which sometimes necessitates surgical evacuation. 
In a large series of 204 patients who went cervical epidural injections, corticosteroids were injected at C7-T1 level for cervical radiculopathy in 142 patients over a period of 1 year. In this study the author Cicala RS et al., reported two dural punctures and one episode of upper extremity weakness, which resolved in next 24 hrs.  Reitman C et al., reported a case of acute onset of axial pain followed by progressive quadriparesis within 8 hrs of cervical epidural injection. Computed tomography (CT) scan suggested posterior cord displacement consistent with an anterior spinal hematoma from C3-C5. Surgical exploration revealed an anterior subdural hematoma that was evacuated followed by dural closure with a patch.  Where as in our patient there was gradual progressive recovery of motor and sensory function. This may reflect the resolution of edema and reabsorbtion of the hematoma.
Anatomical factors such as vertebral abnormalities, technical errors like traumatic spinal tap, multiple attempts at needle placement, and pharmacological factors such as use of anti-platelet and anticoagulant therapy may be implicated in the formation and progress of spinal epidural hematoma.  It may also occur rarely in patients with no history of coagulopathy and anticoagulative medications.
In any patient with symptom of severe local or radiating pain during epidural injection or catheterization should be regarded as a possibility of mechanical stimulation of spinal cord or a nerve root and the needle should be withdrawn immediately. Use of fluoroscopic guidance does not guarantee against accidental trauma to spinal cord.  If symptoms and physical signs persist patient should undergo detailed neurological examination and MRI of the cord to demonstrate the injury. The value of high dose steroids is not known in case of spinal cord hematoma however its use should be considered. However use of intravenous methylprednisolone within eight hours of injury has been shown to improve neurological outcome in other forms of acute spinal cord injury. 
Guidelines suggested  to prevent injury to nerve is:
- Use blunt tip needle instead of a sharp bevelled needle ,
- Use 22 gauge rather than 25 gauge needle
- Be gentle so patient can report parasthesia
- Elicit the parasthesia by nerve stimulator to avoid mechanical damage in to the nerve
- Avoid injections in to confined facial spaces such as lunar or peritoneal nerve
- Use the minimum concentration of local anaesthetic
Initial treatment usually consists of activity modification, NSAID's, physical therapy and narcotic analgesics and analgesic adjuvant when pain is not adequately controlled. If there is no improvement in 3-4 weeks of conservative treatment, cervical epidural steroid injections may be performed.
Majority of the patients respond well to epidural steroid injection but it is impossible to judge the severity of complication after central neuraxial blockade and this makes decision making a challenge for pain physician.
| Conclusion|| |
Despite of optimisation of all the relevant patient factors including anticoagulant therapy, use of the appropriate technique and the appropriate imaging modalities; neuraxial hematoma may still occur spontaneously. The occurring of complications in medical or surgical practice is a known fact. However dealing with it promptly leads to no mortality or minimum morbidity and should be the ultimate goal.
The suggested protocol of guidelines of precautions will go long way in goal of complication free Total Pain Management.
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[Figure 1], [Figure 2]