Acute Epidural Hematoma Following a Cervical Epidural Injection in a Patient without Bleeding Risk

Abstract

An acute epidural hematoma following a cervical interlaminar epidural injections is rare, but when it occurs, it can be associated with devastating complications if appropriate corrective action is not taken. Surgical decompression or conservative management has been proposed in managing acute epidural hematoma, based on the progression of symptomatology with neurologic dysfunction. We report a case of a cervical epidural hematoma in a healthy 43-year-old functioning female patient without overt risk factors for procedural hemorrhagic complications including baseline coagulopathy, baseline dysfunction, and intake of anticoagulants. There were no technical difficulties in performing the procedure. The patient developed symptomatology consisting of neck pain, left upper extremity pain, weakness in the left lower extremity, and inability to urinate following the cervical interlaminar epidural. Unbeknownst to the provider, who had performed the epidural injection, the patient presented to the local emergency room and underwent a workup to rule out cardiac etiologies for her symptoms. The patient was also given ketorolac intravenously for neck pain. The provider who performed the epidural injection was informed 18 hours post-procedure. The patient had progressive symptomatology with neurological dysfunction including weakness and numbness. The provider suspected an epidural hematoma. As a result, an emergent magnetic resonance imaging (MRI) was performed, which showed a significant collection of blood within the epidural space, which clinically required surgical decompression. Subsequently, surgical decompression was carried out with full recovery of neurologic function. Issues in managing an acute epidural hematoma are related to avoidance of drugs increasing hemorrhagic complications and rapid diagnosis with appropriate therapy, with shared decision making. These hematomas can be managed conservatively or with surgery. Nonsurgical management is influenced by the initial neurological presentation and spontaneous recovery or at least lack of progression of the deficit. After reasonable monitoring, if stable status is absent and neurological dysfunction is increasing, then surgical decompression is recommended. Key words: Cervical epidural injection, cervical epidural hematoma, bleeding risk factors, surgical decompression, nonsurgical management, ketorolac