American Journal of Physical Medicine & Rehabilitation:
From the Departments of Physical Medicine and Rehabilitation (MML, GK) and Neuroradiology, William Beaumont Hospital, Royal Oak, Michigan (I-MW).
All correspondence and requests for reprints should be addressed to Myron M. LaBan, MD, MMSc, Department of Physical Medicine and Rehabilitation, William Beaumont Hospital, Royal Oak, MI 48073.
Epidural corticosteroid injections for intractable spinal pain, although often reputed to be innocuous, are not without risk. Both spinal epidural abscess formation and epidural hematomas1 have been reported after routine epidural corticosteroid injections for spinal radicular pain associated with disc herniations and/or spinal stenosis.
Four cases of epidural hematomas have been reported previously in the last 10 yrs; here, two additional cases are described.
A 36-yr-old female received three epidural steroid injections for cervical radiculopathy. After the second injection, she developed numbness and tingling in her hands. Magnetic resonance imaging demonstrated a hematoma from C3 to T3 (Fig. 1). An emergent surgical evacuation of the hematomas was completed the same day. She experienced both bladder and bowel incontinence. Strength was normal in the upper extremities, with minimal weakness in the lower extremities. Sensation was normal in the upper extremities but was diminished between T4 and T11. At discharge, she was able to ambulate independently for 150 feet with a rolling walker.
A 79-yr-old female was admitted to the hospital for an elective epidural steroid injection with symptoms of intractable lumbar spinal stenosis. Coumadin, which had been prescribed for atrial fibrillation, was discontinued, and she was started on IV heparin. Two days later, she was given an epidural corticosteroid injection. She subsequently developed paraparesis. A computed tomographic myelogram demonstrated a hematoma from T2 to T8 with cord compression (Fig. 2). Her anticoagulation was reversed and a decompressive thoracic laminectomy was performed the next day. The patient remained paraparetic with both a neurogenic bowel and bladder. She was discharged to a subacute rehabilitation facility after 1 mo of acute rehabilitation, able to transfer and propel her wheelchair 150 feet.
Reports of epidural hematomas after epidural corticosteroid injections are relatively infrequent, asymptomatic, and/or unreported.
Since Jackson2 first described the epidural hematoma in 1869, numerous etiologic agents have been reported, including surgery, trauma, anticoagulation, arterial venous malformations, pregnancy, anticoagulation therapy, and lumbar puncture. Disruption of the integrity of the internal vertebral plexus of Batson has been cited in these instances as a potential source of bleeding.3 As demonstrated by Tarlov et al.,4 recovery of spinal neurological function is dependent on both the magnitude and duration of the cord compression antecedent to surgery. Anticipating the risk of an epidural bleed is contingent on identifying and managing predisposing risk factors including, among others, anticoagulation therapy, and also on weighing the benefits of the procedure. Preprocedure disclosure should continue to acknowledge the relatively rare but potentially devastating consequences of either an epidural spinal hematoma and/or infection.
1. Stoll A, Sanchez M: Epidural hematoma after epidural block: implications for its use in pain management. Surg Neurol
2. Jackson R: Case of spinal apoplexy. Lancet
3. Green RJM, Ponssen H: The spontaneous spinal epidural hematoma: a study of the etiology. J Neural Sci
4. Tarlov IM, Klinger H, Vitale S: Spinal cord compression studies: 1: experimental techniques to produce acute and gradual compression. Arch Neurol Psychiatry