Poster 471 Anticoagulation in New Onset Atrial Fibrillation Directly after Epidural Steroid Injection Causing Epidural Hematoma: A Case Report

Abstract

reduction with opening in the intervertebral disc, reduction of herniated disc volume, separation of the disc and adjoining nerve root, and widening of the facet joint while under traction. The mean length of the lumbar vertebral column of all patients was 165.3 mm before applying traction and 166.5 mm, 167.3 mm, and 167.7 mm after 10, 20, and 30 minutes of traction, respectively. Compared to the mean vertebral column length before traction, elongation by 1.45% had occurred after 30 minutes of traction. Reduction ratios were 8.57%, 15.24%, and 17.94% after 10, 20, and 30 minutes of traction, respectively. Conclusions: We verified sagittal elongation of lumbar spine and disc reduction with lumbar traction through real-time MRI. It is confirmed that there're statistically significant changes in disc when traction is applied. A 74-year-old woman, with history of hyperlipidemia, underwent her second epidural steroid injection (ESI) for treatment of lumbar back pain. Post-injection, she was immediately found to have new onset atrial fibrillation with rapid ventricular rate. She was started on Cardizem and heparin drip for rate control and anticoagulation and admitted to the hospital. Two days later she reported numbness and weakness in her bilateral lower extremities more prominent on the right side, which quickly progressed to bilateral paraplegia. Heparin drip was stopped. MRI showed a 7cm epidural hematoma (EH) from L1-L2 to L4. Neurosurgery performed an emergency laminectomy and medial facetectomy for L1-3 and evacuation of the hematoma. After the procedure she had flaccid paralysis, intact temperature sensation, absent vibration in both legs, and new onset constipation and urinary retention. Setting: Tertiary Care Community Hospital. Results or Clinical Course: While in inpatient rehabilitation the patient was found to have a left popliteal vein DVT and subsequent PE for which she was started on heparin drip bridged to coumadin and IVC filter was placed. Her hip flexors and knee flexors/extensors improved slightly to 3/5 and 2/5 respectively with flaccid paralysis distally. Discussion: Anticoagulation is the second most common cause of EH, with incidence of 1 in 15,000 after low dose heparin and epidural/spinal anesthesia. Typically, antiplatelet agents and anticoagulants are held from 6 to 24 hours prior to the procedure to allow normalization of the coagulation factors, however this practice varies by physician. Time frame to restart antiplatelet and particularly anticoagulant medications is anecdotal. No studies have proven a safe time to start them after ESI. In this patient's case, the risks and benefits must be cautiously reviewed in an emergency such as new onset atrial fibrillation. Conclusions: We would propose the need for establishing guidelines based on current research data on when to initiate anticoagulation after spinal epidural injections. The need for guidelines becomes particularly important in emergency situations when the risks of anticoagulation are extremely high. Objective: To describe a pe...