Unilateral Presentation of a Large Epidural Hematoma

Zink, Michael; Rath, M; Waltensdorfer, Andreas; Engler, Jörg; Rumpold-Seitlinger, Gudrun; Toller, Wolfgang; Reinhardt, Frank

doi:10.1097/00000542-200304000-00052

Cited by 6 publications

(2 citation statements)

References 7 publications

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“…There were only 3 reports of bleeding complications when anticoagulant therapy was continued for interventional techniques (176,177,388). However, there is an abundance of literature with complications related to anesthesia and surgery (209,(212)(213)(214)216,217,219,220,224,(226)(227)(228)230,242,248,253,258,259,262). Further, Manchikanti et al (81), in assessing the frequency of adverse effects during interventional pain management techniques, showed bleeding complications with epidural hematoma in 26 instances compared to 29 instances where antiplatelet and warfarin therapy was discontinued.…”

Section: Se277mentioning

confidence: 99%

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Atlantic

Manchikanti

Benyamin³

et al. 2013

Pain Phys

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Background: Interventional pain management is a specialty that utilizes invasive procedures to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving exogenous anticoagulants and antithrombotics. Even though the risk of major bleeding is very small, the consequences can be catastrophic. However, the role of antithrombotic therapy for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events is also crucial. Overall, there is a paucity of literature on the subject of bleeding risk in interventional pain management along with practice patterns and perioperative management of anticoagulant and anti-thrombotic therapy. Study Design: Best evidence synthesis. Objective: To critically appraise and synthesize the literature with assessment of the bleeding risk of interventional techniques including practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Methods: The available literature on the bleeding risk of interventional techniques and practice patterns and perioperative management of anticoagulant and antithrombotic therapy was reviewed. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through December 2012 and manual searches of the bibliographies of known primary and review articles. Results: There is good evidence for the risk of thromboembolic phenomenon in patients who discontinue antithrombotic therapy, spontaneous epidural hematomas occur with or without traumatic injury in patients with or without anticoagulant therapy associated with stressors such as chiropractic manipulation, diving, and anatomic abnormalities such as ankylosing spondylitis, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation may occur with interventional techniques when antithrombotic therapy is continued, the risk of thromboembolic phenomenon is higher than the risk of epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques, to continue phosphodiesterase inhibitors (dipyridamole [Persantine], cilostazol [Pletal], and Aggrenox [aspirin and dipyridamole]), and that anatomic conditions such as spondylosis, ankylosing spondylitis and spinal stenosis, and procedures involving the cervical spine; multiple attempts; and large bore needles increase the risk of epidural hematoma; and rapid assessment and surgical or nonsurgical intervention to manage patients with epidural hematoma can avoid permanent neurological complications. There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy clopidogrel (Plavix), ticlopidine (Ticlid), or prasugrel (Effient) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) to discontinue to avoid bleeding and epidural hematomas during interventional techniques and to continue to avoid cerebrovascular and cardiovascular thromboembolic events. Recommendations: The recommendations derived from the comprehensive assessment of the literature and guidelines are to continue NSAIDs and low dose aspirin, and phosphodiesterase inhibitors (dipyridamole, cilostazol, Aggrenox) during interventional techniques. However, the recommendations for discontinuation of antiplatelet therapy with platelet aggregation inhibitors (clopidogrel, ticlopidine, prasugrel) is variable with clinical judgment to continue or discontinue based on the patient’s condition, the planned procedure, risk factors, and desires, and the cardiologist’s opinion. Low molecular weight heparin (LMWH) or unfractionated heparin may be discontinued 12 hours prior to performing interventional techniques. Warfarin should be discontinued or international normalized ratio (INR) be normalized to 1.4 or less for high risk procedures and 2 or less for low risk procedures based on risk factors. It is also recommended to discontinue Pradaxa for 24 hours for paravertebral interventional techniques in 2 to 4 days for epidural interventions in patients with normal renal function and for longer periods of time in patients with renal impairment, and to discontinue rivaroxaban for 24 hours prior to performing interventional techniques. Limitations: The paucity of the literature. Conclusion: Based on the available literature including guidelines, the recommendations in patients with antithrombotic therapy for therapy prior to interventional techniques are provided. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions

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Section: Se277mentioning

confidence: 99%

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Atlantic

Manchikanti

Benyamin³

et al. 2013

Pain Phys

View full text Add to dashboard Cite

show abstract

“…Indomethacin has been implicated in the development of a cervical epidural hematoma following repeat cervical epidural steroid injections (218). The combined use of naproxen and diclofenac has been implicated in the development of a large epidural hematoma following a subarachnoid puncture (219). MacDonald suggests withholding aspirin for 7-10 days and obtaining a bleeding time prior to epidural catheter placement (220).…”

Section: Aspirin and Non Steroidal Anti-inflammatory Drugsmentioning

confidence: 99%

Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature

Raj¹

2004

Pain Phys

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Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors

Lagerkranser

2017

Scandinavian Journal of Pain

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AbstractBackgroundBleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.MethodsMEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.ResultsAltogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs. Conclusions and implicationsThe annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.

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Unilateral Presentation of a Large Epidural Hematoma

Cited by 6 publications

References 7 publications

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature

Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors

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