Cervical interlaminar epidural
steroid injections (ESIs) are commonly performed as one part of a multi-modal
analgesic regimen in the management of upper extremity radicular
pain.
Spinal epidural hematoma (SEH) is a rare complication with a reported incidence ranging from 1.38 in 10,000 to 1 in 190,000 epidurals. Current American Society of
Regional Anesthesia (ASRA), American Society of Interventional
Pain Physicians (ASIPP), and the International Spine Intervention Society (ISIS) recommendations are that non-steroidal anti-inflammatory drugs (
NSAIDs) do not need to be withheld prior to
epidural anesthesia. We report a case wherein intramuscular
ketorolac and oral
fluoxetine contributed to a SEH and
tetraplegia following a cervical interlaminar (ESI). A 66 year-old woman with
chronic renal insufficiency and
neck pain radiating into her right upper extremity presented for evaluation and was deemed an appropriate CESI candidate. Cervical magnetic resonance imaging (MRI) revealed multi-level neuroforaminal
stenosis and
degenerative intervertebral discs. Utilizing a loss of resistance to saline technique, an 18-gauge Tuohy-type needle entered the epidural space at C6-7. After negative aspiration, 4 mL of saline with 80 mg of methyl-
prednisolone was injected. Immediately thereafter, the patient reported significant spasmodic-type localized
neck pain with no neurologic status changes. A decision was made to administer 30 mg intramuscular
ketorolac as treatment for the spasmodic-type
pain. En route home, she developed a sudden onset of acute
tetraplegia. She was brought to the emergency department for evaluation including platelet and coagulation studies which were normal. MRI demonstrated an epidural
hematoma extending from C5 to T7. She underwent a bilateral C5-T6
laminectomy with epidural
hematoma evacuation and was discharged to an acute inpatient rehabilitation hospital.
Chronic renal insufficiency,
spinal stenosis, female gender, and increasing age have been identified as risk factors for SEH following
epidural anesthesia. In the present case, it is postulated that after the spinal vascular system was penetrated, hemostasis was compromised by the combined antiplatelet effects of
ketorolac,
fluoxetine,
fish oil, and
vitamin E. Although generally well tolerated, the role of
ketorolac, a potent anti-platelet medication used for
pain relief in the peri-neuraxial intervention period, should be seriously scrutinized when other
analgesic options are readily available. Although the increased risk of
bleeding for the alternative medications are minimal, they are nevertheless well documented. Additionally, their additive impairment on hemostasis has not been well characterized. Withholding
NSAIDs,
fluoxetine,
fish oil, and
vitamin E in the peri-procedural period is relatively low risk and should be considered for all patients with multiple risk factors for SEH.