Lumbar Epidural Hematoma Following Interlaminar Fluoroscopically Guided Epidural Steroid Injection:

Safety of fluoroscopically guided pain procedures in patients receiving cytotoxic chemotherapy: a retrospective analysis

PURPOSE

To examine the incidence of bleeding and infectious adverse events (AEs) in patients undergoing interventional, fluoroscopic-guided axial spine procedures to modulate pain.

METHODS

Retrospective data of patients undergoing fluoroscopically guided axial spine injections at a single tertiary care medical center Cancer Rehabilitation program in the USA were reviewed. AEs, type of chemotherapy, type of tumor, age, platelet and absolute neutrophil counts (ANC) prior to the procedure, and relevant past medical history were collected. Descriptive statistical analyses were performed.

RESULTS

Sixty-three separately identifiable procedures across 28 patients met inclusion criteria. Zero AEs were recorded. Platelet and ANC were generally above the recommended safety threshold, but granulocyte colony stimulating factor was administered prior to four procedures to boost ANC levels. Multiple myeloma was the most common cancer diagnosis (64.3%). Various solid tumors made up the remaining cancer diagnoses. Epidural steroid injections (n=23) and medial branch blocks (n=23) were the most common procedures performed and lumbar (n=35) was the most common location of procedures. Three patients died within 30 days of the procedures but their deaths were not directly attributable to the injections.

CONCLUSION

This provides preliminary data to support the safety of injections in patients receiving cytotoxic chemotherapy. Larger, multicenter studies are required before firm conclusions can be drawn.

Efficacy of acupuncture for sciatica: study protocol for a randomized controlled pilot trial

BACKGROUND

Acupuncture is widely used for pain diseases while evidence of its efficacy for sciatica is insufficient. We aim to explore the feasibility and efficacy of acupuncture with different acupoint selecting strategies for sciatica induced by lumbar disc herniation.

METHODS

This is a multicenter, three-arm, patient-assessor-blinded randomized controlled pilot trial. Ninety patients will be assigned randomly into 3 groups including disease-affected meridians (DAM) group, non-affected meridians (NAM) group, and sham acupuncture (SA) group in a 1:1:1 ratio. The trial involves a 4-week treatment along with follow-up for 22 weeks. The primary outcome is the change of leg pain intensity measured by the visual analogue scale (VAS) from baseline to week 4 after randomization. Secondary outcomes include functional status, back pain intensity, and quality of life. Adverse events will also be recorded.

DISCUSSION

The results will inspire the optimal acupuncture strategy for sciatica and help establish a better design as well as power calculation for a full-scale study.

TRIAL REGISTRATION

ChiCTR2000030680 (Chinese Clinical Trial Registry, http://www.chictr.org.cn , registered on 9 March 2020).

Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort

OBJECTIVES

To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagulation effect.

DESIGN

Retrospective chart review of a 12-month period.

SETTING

Outpatient academic medical practice.

INTERVENTIONS

Injections during outpatient interventional spine clinical encounters, including 14 cervical transforaminal epidural steroid injections, 26 cervical medial branch blocks, seven cervical radiofrequency neurotomies, three cervical facet joint injections, 88 lumbar transforaminal epidural steroid injections, 66 lumbosacral medial branch blocks, 18 lumbosacral radiofrequency neurotomies, 13 lumbar facet joint injections, one caudal epidural steroid injection, 11 sacral transforaminal epidural steroid injections, and 32 sacroiliac joint injections.

MAIN OUTCOME MEASURE

Epidural hematoma or other serious bleeding.

RESULTS

In this cohort of 275 consecutive encounters with available records in which patients underwent a spinal injection while continuing medications with antiplatelet or anticoagulant effect, zero of the 275 clinical encounters (0%, 95% confidence interval = 0-1.4%) resulted in epidural hematoma or other serious bleeding. For antiplatelet medication, nonsteroidal anti-inflammatory drugs were continued in 102 procedures, aspirin in 142, clopidogrel in 21, and meloxicam and/or Celebrex in 81; for anticoagulation medication, warfarin was continued in four procedures, apixaban in six, dabigatran in one, and fondaparinux in two. Of note, one patient suffered a deep vein thrombosis, which was identified at two-week follow-up despite continuing aspirin therapy.

CONCLUSIONS

This cohort adds to the growing evidence that the risk of serious bleeding complications from select spine interventions while continuing medications with antiplatelet or anticoagulant effect appears low.

Epidural Hematoma After Trans-Sacral Epiduroscopic Laser Decompression: A Case Report

Objective: In this study, we report a patient who developed lumbar epidural hematoma after trans-sacral epiduroscopic laser decompression (SELD). Background: SELD is a nonoperative minimally invasive spinal procedure, in which a herniated lumbar disk can be ablated by laser. Because of the rich epidural venous plexus, the procedure might have a risk of epidural hematoma. Materials and methods: A 57-year-old woman underwent the SELD procedure for the treatment of lower back and right buttock pain due to disk protrusion at L5-S1. One day after the procedure, complete motor weakness was observed in the right leg. Results: Lumbar magnetic resonance imaging revealed epidural hematoma at the L1-L5 levels, compressing the thecal sac. Using a posterior approach, decompressive subtotal laminectomy on L1 and total laminectomy on L2-L5 with evacuation of the hematoma were performed. Two months postoperatively, near complete resolution of the motor weakness in the right leg was observed. Conclusions: Clinicians should keep in mind the likelihood of epidural hematoma after SELD.

Cervical epidural hematoma following interlaminar epidural steroid injection via the contralateral oblique view in patient taking omega-3 fatty acids

Background and objectives

We sought to describe a case of an epidural hematoma after a cervical interlaminar epidural steroid injection (ILESI) performed using contralateral oblique view. We also discuss factors that could have placed this patient at increased risk, including concurrent use of omega-3 fatty acids and non-steroidal anti-inflammatory medications.

Case report

A 74-year-old woman returned to the pain clinic, within 15 min of discharge, after an apparent uncomplicated cervical ILESI using the contralateral oblique technique with severe periscapular pain and muscle spasms. Cervical MRI showed a large epidural hematoma which was subsequently emergently evacuated. On postoperative examination, the patient had no neurologic deficits and full resolution of her painful symptoms.

Conclusions

To our knowledge, this is the first reported case of cervical epidural hematoma in which the contralateral oblique technique was used. Also, this is the second case in which the combination of non-steroidal anti-inflammatory medications and omega-3 fatty acids has been considered as a contributor to increased hematoma risk. This case underscores the risk of epidural hematoma using a novel fluoroscopic technique and the need for potential discontinuation of supplements like omega-3 fatty acids.

Epidural hematoma after caudal epidural pulsed radiofrequency stimulation: A case report

RATIONALE

Epidural hematoma is a possible complication after neuraxial procedures. Recently, caudal epidural pulsed radiofrequency (PRF) stimulation was reported as an effective method for controlling several types of chronic pain. Herein, we report on a patient who developed a lumbar epidural hematoma after receiving caudal epidural PRF stimulation.

PATIENT CONCERNS

A 75-year-old woman, who was taking oral warfarin (2 mg/d), received caudal epidural PRF stimulation for symmetrical neuropathic pain in both legs due to chronic idiopathic axonal polyneuropathy. She did not discontinue warfarin use before undergoing the procedure. Three days and 12 hours after the procedure, motor weakness suddenly manifested in the right leg (manual muscle testing [MMT] = 2-3).

DIAGNOSES

Lumbar magnetic resonance imaging (MRI) performed 7 days after the PRF procedure showed a spinal epidural hematoma at the L1 to L5 levels, compressing the thecal sac. The international normalized ratio was 6.1 at the time of the MRI.

INTERVENTIONS

Decompressive laminectomy from L1 to L5 with evacuation of the hematoma was performed.

OUTCOMES

Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5.

LESSONS

This case suggests that clinicians should carefully check if patients are taking an anticoagulant medication and ensure that it is discontinued for an appropriate length of time before a caudal epidural PRF procedure is performed.

Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines

Setting

Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections.

Objective

To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines.

Design

Prospective descriptive study.

Subjects

Patients undergoing interventional spine injections from a interventional physiatrist's practice.

Methods

A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events.

Results

Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications.

Conclusions

Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.

Visualization of Needle-Tip Localization by Ultrasound Guidance with Contrast Bubble in Lumbar Selective Nerve Root Block: Clinical Pilot Study

BACKGROUND

Epidural steroid injection for low back and leg pain has been shown to result in a positive clinical outcome. Lumbosacral selective nerve root block (SNRB) via a transforaminal approach is commonly performed under fluoroscopic guidance. However, ultrasound guidance is an alternative to overcome the radiologic disadvantages. This study examined the accuracy of needle-tip localization under ultrasound guidance with a contrast bubble, compared with fluoroscopic guidance.

OBJECTIVE

The primary objectives were to envisage the needle-tip localization with an air bubble by ultrasound and also to determine the accuracy of needle-tip location in transforaminal lumbar SNRB for low back and leg pain patients who were not surgical candidates.

METHODS

A prospective study of 30 SNRBs was conducted. An air bubble was produced and was used to envisage the needle-tip location under ultrasound guidance. Finally, the needle tip was confirmed by fluoroscopy. The accuracy of needle-tip location was statistically analyzed.

RESULTS

Twenty-four SNRBs were performed at L4-5 and 6 SNRBs at L3-4. The accuracy of needle-tip localization was 80%.

CONCLUSION

In order to avoid radiation exposure during the SNRB procedure, ultrasound guidance might be an alternative. Despite being accepted practice, there is a steep learning curve involved in the use of ultrasound guidance for lumbar SNRB, and proper training is crucial. A contrast bubble is a prospective enhancement for better visualization of ultrasound guidance.