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

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  1. IPM;2017;11-17 Prevalence of Epidural Hematoma Following Cervical Epidural Injections in Interventional Pain Management Settings: Literature Review with Two Case Reports
    Case Report/Literature Review
    Laxmaiah Manchikanti, MD, Yogesh Malla, MD, Ramsin M. Benyamin, MD, and Joshua A. Hirsch, MD.

Epidural injections are performed frequently in managing chronic neck pain secondary to disc herniation, spinal stenosis, discogenic pain, and post cervical surgery syndrome. Major risks and devastating complications have been reported with cervical transforaminal epidural injections. Cervical interlaminar epidural injections have been considered as safe and effective in managing chronic spinal pain of multiple origins.  Epidural hematoma is one of the rare complications.
Efforts at prevention of cervical epidural hematoma have focused on avoidance of the procedures or cessation of therapy in patients with bleeding disorders, on antiplatelet therapy, fish oil, and multiple other drugs. The guidelines from multiple organizations have provided variable recommendations regarding the need to stop nonsteroidal anti-inflammatory drugs (NSAIDs) including low dose aspirin and antithrombotic agents. The risks of thrombotic events have been reported to be higher than of bleeding during surgery or interventional techniques with discontinuation of antiplatelet therapy.
We looked at a 16 year span of cervical interlaminar epidural injections (2000 through 2015), performed in a single facility during which time there were two epidural hematomas. The first patient was managed conservatively while the second patient required surgical intervention. Both patients recovered without residual complications. During the same period, 2 cases of cardiovascular events were reported in our practice associated with the cessation of antithrombotic therapy. They also recovered without residual complications. Nevertheless, rapid diagnosis is crucial as manifested by increased or unusual axial pain at the site of injection which is often different from patient’s previous experience.
Two cases provided a prevalence rate of 0.0085% (2/23,552) over 16 years at this facility. Based on occurrence of the year, the prevalence was one of 2,604 cases, or 0.03%, in 2012 and one of 2,287 cases, or 0.04%, in 2015. This provides a prevalence rate of 0.085 per 10,000 procedures. Even though complications are extremely rare, it is essential to weigh the risk benefit ratio of these procedures and select the patients with extreme caution and perform the procedures with diligence.
Key words: Interventional techniques, bleeding disorders, aspirin, antithrombotic agents, cervical epidural injection, cervical epidural hematoma