Epidural hematoma after caudal epidural pulsed radiofrequency stimulation

Abstract

Rationale:Epidural hematoma is a possible complication after neuraxial procedures. Recently, caudal epidural pulsed radiofrequency (PRF) stimulation was reported as an effective method for controlling several types of chronic pain. Herein, we report on a patient who developed a lumbar epidural hematoma after receiving caudal epidural PRF stimulation.Patient concerns:A 75-year-old woman, who was taking oral warfarin (2 mg/d), received caudal epidural PRF stimulation for symmetrical neuropathic pain in both legs due to chronic idiopathic axonal polyneuropathy. She did not discontinue warfarin use before undergoing the procedure. Three days and 12 hours after the procedure, motor weakness suddenly manifested in the right leg (manual muscle testing [MMT] = 2–3).Diagnoses:Lumbar magnetic resonance imaging (MRI) performed 7 days after the PRF procedure showed a spinal epidural hematoma at the L1 to L5 levels, compressing the thecal sac. The international normalized ratio was 6.1 at the time of the MRI.Interventions:Decompressive laminectomy from L1 to L5 with evacuation of the hematoma was performed.Outcomes:Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5.Lessons:This case suggests that clinicians should carefully check if patients are taking an anticoagulant medication and ensure that it is discontinued for an appropriate length of time before a caudal epidural PRF procedure is performed.

Progressive unilateral leg weakness after lumbar decompression due to ischemic monomelic neuropathy misdiagnosed as epidural hematoma: A CARE-compliant case report

“…[ 8 , 9 ] The clinical symptoms include sudden radicular pain, motor weakness, and sensory deficit in unilateral or bilateral lower extremities. [ 8 , 9 ] Hours to days after their initiation, symptoms insidiously progress. The clinical features of spinal epidural hematoma are similar to those of IMN.…”

“…[7] Moreover, the degree of motor weakness caused by spinal epidural hematoma is aggravated over time. [7][8][9] In patients with motor weakness following lumbar spine surgery, the cause should be accurately diagnosed through physical examination, laboratory studies, and imaging studies, and appropriate treatment should be provided in a timely manner. In the current study, we report a patient with progressive acute motor weakness combined with pain in the unilateral lower extremity due to acute occlusion of the common femoral artery; however, the patient was initially suspected to have spinal epidural hematoma because the motor weakness was initiated 5 days after spinal surgery and progressed.…”

“…[7] Moreover, the degree of motor weakness caused by spinal epidural hematoma is aggravated over time. [7–9]…”

Caudal Epidural Steroid Injections in the Setting of Remaining on Antithrombotics: A Retrospective Study

“…Moderate and severe central canal stenosis at the L5/S1 level is relatively uncommon compared to at the L2/L3, L3/4, and L4/5 levels (27). While there have been cases of symptomatic epidural hematomas at sites remote from the location of the procedure needle, this is not a common phenomenon (24,(28)(29)(30). Thus, while epidural hematomas may or may not be unusual in the setting of caudal ESIs, we hypothesize that when they do develop, they are less likely to be clinically relevant than those in the lumbar spine where ESIs are typically performed at or very close to sites of significant neural compression.…”

“…Possibilities included cilostazol, the underlying spinal stenosis, interventional violence, or a combination of all" (24). The second case described a 75-year-old woman taking warfarin, in whom a caudal epidural "pulsed radiofrequency procedure" was performed (28). The procedural needle was a 22-gauge cannula, which was advanced to the S3 level.…”