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Final Program

1268 - Subdural Hematoma Following Epidural Steroid Epidural Injection

Thursday, February 27, 2025
5:00 PM - 6:30 PM MST

    Co-Author(s)

  • CT

    Chau Tran, DO

    PGY-4 Resident in PM&R
    University of New Mexico PM&R Residency
    Albuquerque, New Mexico, United States

  • ZB

    Zackery Billington, DO

    Assistant Professor
    University of New Mexico
    Albuquerque, New Mexico, United States

    • Presenting Author(s)

  • RA

    Robert Allen, MD

    PGY-3 Resident in PM&R
    University of New Mexico
    Albuquerque, New Mexico, United States

    • Co-Author(s)

  • DM

    David Majure, MD

    PGY-3 Resident in PM&R
    University of New Mexico
    Albuquerque, New Mexico, United States

Case Diagnosis: Acute Spinal Subdural Hematoma

Case Description: A 70-year-old female with PMH of HTN and hx of CVA on Eliquis presented initially to an outside facility with right sided flank pain after an interventional procedure (subsequently found to be epidural CSI). The patient developed bilateral lower extremity weakness and sensation loss immediately after the procedure and was transferred to our hospital. MRI showed epidural hematoma with spinal cord compression from T11-S1. She was taken to the OR for emergent spinal cord decompression. PM&R was consulted POD1 and recommended discharge to IPR. ASIA Exam was completed on POD 11 and the patient was determined to be T11 ASIA A. Remainder of stay at IPR was uncomplicated, she was discharged to the community with routine follow-up.



Discussions:

Although serious bleeding complications from ESI while continuing anticoagulation appear low, there is still a risk. The American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines stratify ESI into intermediate-risk procedures and recommend holding AC for 3 days.  



Given the patient’s new paraplegia after injection, it is not definitive whether epidural hematoma was iatrogenic or spontaneous. However, spinal subdural hematoma (SSDH) is exceedingly uncommon and spontaneous SSDH is even rarer with no definite guidelines for management. In this case, the patient had rapidly progressive neurological symptoms, early diagnosis, and prompt surgical interventions. Unfortunately, she was discharged with a complete paraplegic spinal cord injury. 


Conclusions: This case highlights the importance of not underestimating the risk of subdural hematomas with spinal interventions, especially in patients on AC. This is especially relevant given that large-scale studies have demonstrated an increasing prevalence of anticoagulant use for stroke prevention. Shared decision-making and thorough explanation of risks must be discussed. Regardless, spinal bleeding should be suspected of any neurological deficits following ESIs.