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Dehaene S, Biesemans J, Van Boxem K, Vidts W, Sterken J, Van Zundert J. Post-Dural Puncture Headache Evolving to a Subdural Hematoma: A Case Report. Pain Pract 2020; 21:83-87. [PMID: 32652880 PMCID: PMC7818122 DOI: 10.1111/papr.12937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 12/25/2022]
Abstract
Introduction Cervical epidural corticosteroid injections are frequently used for the treatment of subacute cervicobrachial pain. This therapy is considered safe, with the vast majority of the complications being minor and transient. Case Report We present a case of a woman in her fifties who suffered from cervicobrachialgia and received 2 cervical epidural corticosteroid infiltrations. On day 3 after the second infiltration, a new headache appeared and on day 16 a bilateral subdural hematoma was visualized on CT scan. Complete resorption of the hematoma was seen on day 25 without surgical intervention. Discussion Up until now, only 1 case report of an intracranial subdural hematoma after a cervical epidural steroid injection has been published. But several cases of an intracranial subdural hematoma after spinal, epidural, or combined spinal and epidural anesthesia have been reported. Physicians should be aware of this potentially dramatic complication since post‐dural puncture headache after any type of procedure can evolve into a subdural hematoma. Clinical differentiation between the two can be difficult; post‐dural puncture headache is characterized by relief of symptoms in the supine position and photophobia/phonophobia. A subdural hematoma should be considered if the headache changes in character, does not respond to treatment, or there are neurological signs such as nausea/vomiting and blurred vision. Immediate medical imaging should then be performed.
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Affiliation(s)
- Seppe Dehaene
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium.,Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jeroen Biesemans
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Koen Van Boxem
- Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wesley Vidts
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Joeri Sterken
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, OLV van Lourdes Ziekenhuis, Waregem, Belgium
| | - Jan Van Zundert
- Department of Anesthesiology, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Szeto V, Kosirog J, Eilbert W. Intracranial subdural hematoma after epidural anesthesia: a case report and review of the literature. Int J Emerg Med 2018; 11:36. [PMID: 31179908 PMCID: PMC6135040 DOI: 10.1186/s12245-018-0199-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/26/2018] [Indexed: 12/26/2022] Open
Abstract
Background Intracranial subdural hematoma occurring as a result of a procedure that causes a puncture of the spinal dura mater is extremely rare, with less than 100 cases reported. Often, this condition is initially misdiagnosed and treated as a post dural puncture headache. Case presentation A woman presented to our emergency department complaining of a headache 4 days after receiving epidural anesthesia during uncomplicated childbirth. The headache’s characteristics were consistent with a post dural puncture headache, and the patient was initially treated as such. Computed tomography later revealed the presence of bilateral intracranial subdural hematomas. In light of the patient’s clinical status, treatment involved cautious observation only. Repeat imaging revealed spontaneous resolution of the hematomas, and the patient had a benign clinical course. Conclusions Headaches are common in the postpartum period, often after receiving epidural or spinal anesthesia. While exceptionally rare, intracranial subdural hematoma may occur as a complication of any procedure that results in spinal dural puncture. The possibility of this potentially life-threatening complication must be kept in mind when evaluating these patients.
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Affiliation(s)
- Victor Szeto
- Department of Emergency Medicine, University of Illinois College of Medicine, 1819 West Polk St., Room 469 COME, Chicago, IL, 60612, USA
| | - Justin Kosirog
- Department of Emergency Medicine, University of Illinois College of Medicine, 1819 West Polk St., Room 469 COME, Chicago, IL, 60612, USA
| | - Wesley Eilbert
- Department of Emergency Medicine, University of Illinois College of Medicine, 1819 West Polk St., Room 469 COME, Chicago, IL, 60612, USA.
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Abstract
BACKGROUND AND OBJECTIVE Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports. METHODS Studies were identified by searching PubMed MEDLINE, Ovid MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Library to retrieve all available relevant articles. Publications from the last 20 years (September 1994 to September 2014) were considered for further analysis. Studies selected were English-language original articles publishing results on complications related to the technique used for cervical and lumbar ESIs. The studies had to specify the approach used for injection. All studies that did not fulfil these eligibility criteria were excluded from further analysis. RESULTS Overall, the available literature supports the view that serious complications following injections of corticosteroid suspensions into the cervical and lumbar epidural space are uncommon, but if they occur they can be devastating. CONCLUSIONS The true incidence of such complications remains unclear. Direct vascular injury and/or administration of injectates intra-arterially represent a major concern and could account for the vast majority of the adverse events reported. Accurate placement of the needle, use of a non-particulate corticosteroid, live fluoroscopy, digital subtraction angiography, and familiarisation of the operator with contrast patterns on fluoroscopy should minimise these risks. The available literature has several limitations including incomplete documentation, unreported data and inherent bias. Large registries and well-structured observational studies are needed to determine the true incidence of adverse events and address the safety concerns.
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Subarachnoid Hemorrhage and Spinal Subdural Hematoma Due to Acute CSF Hypotension. Neurocrit Care 2016; 26:109-114. [DOI: 10.1007/s12028-016-0327-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vorobeychik Y, Sharma A, Smith CC, Miller DC, Stojanovic MP, Lobel SM, Valley MA, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2016; 17:2185-2202. [PMID: 28025354 DOI: 10.1093/pm/pnw091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. DESIGN Systematic review. INTERVENTIONS Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. CONCLUSIONS In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.
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Affiliation(s)
- Yakov Vorobeychik
- *Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Anil Sharma
- Spine and Pain Centers, New Jersey and New York
| | - Clark C Smith
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Boston, Massachusetts
| | - Steve M Lobel
- Medical Associates of North Georgia, Canton, Georgia
| | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf 2016; 15:1031-9. [DOI: 10.1080/14740338.2016.1184246] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Byron Schneider
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Patricia Zheng
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Ryan Mattie
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - David J. Kennedy
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
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Kim M, Park KS. Intracranial Chronic Subdural Hematoma Presenting with Intractable Headache after Cervical Epidural Steroid Injection. J Korean Neurosurg Soc 2015; 58:144-6. [PMID: 26361532 PMCID: PMC4564748 DOI: 10.3340/jkns.2015.58.2.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/29/2014] [Accepted: 11/23/2014] [Indexed: 11/30/2022] Open
Abstract
Postdural punctural headache (PDPH) following spinal anesthesia is due to intracranial hypotension caused by cerebrospinal fluid (CSF) leakage, and it is occasionally accompanied by an intracranial hematoma. To the best of our knowledge, an intracranial chronic subdural hematoma (CSDH) presenting with an intractable headache after a cervical epidural steroid injection (ESI) has not been reported. A 39-year-old woman without any history of trauma underwent a cervical ESI for a herniated nucleus pulposus at the C5-6 level. One month later, she presented with a severe headache that was not relieved by analgesic medication, which changed in character from being positional to non-positional during the preceding month. Brain magnetic resonance imaging revealed a CSDH along the left convexity. Emergency burr-hole drainage was performed and the headache abated. This report indicates that an intracranial CSDH should be considered a possible complication after ESI. In addition, the event of an intractable and changing PDPH after ESI suggests further evaluation for diagnosis of an intracranial hematoma.
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Affiliation(s)
- Myungsoo Kim
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ki-Su Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
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Correa AÁ, Díaz RCR, Lotero MAA. Efficacy of epidural methylprednisolone in radicular pain. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Efficacy of epidural methylprednisolone in radicular pain☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543010-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Kaloostian PE, Kim JE, Bydon A, Sciubba DM, Wolinsky JP, Gokaslan ZL, Witham TF. Intracranial hemorrhage after spine surgery. J Neurosurg Spine 2013; 19:370-80. [PMID: 23848351 DOI: 10.3171/2013.6.spine12863] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECT The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome. METHODS The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery. RESULTS The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period. CONCLUSIONS Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.
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Affiliation(s)
- Paul E Kaloostian
- Department of Neurological Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Xu R, Bydon M, Gokaslan ZL, Wolinsky JP, Witham TF, Bydon A. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009; 11:358-64. [PMID: 19769520 DOI: 10.3171/2009.3.spine0916] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Benedetti EM, Siriwetchadarak R, Stanec J, Rosenquist RW. Epidural steroid injections: Complications and management. ACTA ACUST UNITED AC 2009. [DOI: 10.1053/j.trap.2009.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Heran MKS, Smith AD, Legiehn GM. Spinal injection procedures: a review of concepts, controversies, and complications. Radiol Clin North Am 2008; 46:487-514, v-vi. [PMID: 18707959 DOI: 10.1016/j.rcl.2008.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.
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Affiliation(s)
- Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, Canada.
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