Editor-in-Chief: Kenneth D. Candido, MD

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  1. IPM;2017;27-32 Two Cases of Acute Epidural Hematoma Formation after Cervical Interlaminar Epidural Steroid Injections
    Case Report
    John R. Swicegood, MD, Laxmaiah Manchikanti, MD, Ramsin M. Benyamin, MD, and Joshua A. Hirsch, MD.

Cervical interlaminar epidural injections are rarely associated with epidural hematoma resulting in surgical decompression. Multiple strategies in the prevention of epidural hematoma after cervical epidural injections are based on cessation of therapy in patients with bleeding disorders on antiplatelet therapy, fish oil, and multiple other drugs. Multiple guidelines from organizations across the globe have recommended continuation of nonsteroidal anti-inflammatory drugs (NSAIDs) and low dose aspirin. Guidelines also have recommended to continue or cessation of antithrombotic agent therapy based on risk benefit ratio, due to associated risks of thrombotic events with interventional techniques or other surgeries with discontinuation of antiplatelet therapy.
We report 2 cases of cervical epidural hematoma requiring surgical decompression, without residual dysfunction.
The first case was in a 41-year-old Caucasian woman with controlled hypertension; however, with no drug therapy contributing to bleeding and 2 uneventful cervical interlaminar epidural injections, the patient developed a cervical epidural hematoma after the third procedure which was performed uneventfully. She developed rapid paralysis and underwent surgical decompression without residual dysfunction.
The second case involved a cervical epidural injection resulting in a cervical epidural hematoma. This patient was on 81 mg of aspirin and was continued with therapy. Surgical decompression was carried out with no residual dysfunction. This patient also received Toradol for pain control in the recovery room which may have exacerbated the epidural hematoma.
These 2 case reports illustrate that cervical epidural hematoma is a rare, but fatal occurrence associated with cervical epidural injections. Appropriate patient selection with constant vigilance on post operative course and follow-up treatment with surgical intervention or conservative management is crucial. It is also crucial to understand the role of loss of resistance technique with air only which may complicate the closed space phenomenon of cord compression and post procedure pain at the injection site which is different from the pain ever experienced by the patient with the previous injections.
Key words: Interventional techniques, cervical epidural injections, cervical epidural hematoma, bleeding disorders, aspirin, antithrombotic agents, Ketoralac