{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,9]],"date-time":"2025-12-09T15:34:43Z","timestamp":1765294483619},"reference-count":63,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["SPI"],"published-print":{"date-parts":[[2009,9]]},"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3171\/2009.3.spine0916","type":"journal-article","created":{"date-parts":[[2011,2,23]],"date-time":"2011-02-23T21:41:57Z","timestamp":1298497317000},"page":"358-364","source":"Crossref","is-referenced-by-count":50,"title":["Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines"],"prefix":"10.3171","volume":"11","author":[{"given":"Risheng","family":"Xu","sequence":"first","affiliation":[{"name":"Department of Neurosurgery and"},{"name":"Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamad","family":"Bydon","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ziya L.","family":"Gokaslan","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean-Paul","family":"Wolinsky","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Timothy F.","family":"Witham","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ali","family":"Bydon","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"key":"b1-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"2144","DOI":"10.1097\/BRS.0b013e318145a360","article-title":"Complications of interlaminar cervical epidural steroid injections: a review of the literature","volume":"32","author":"Abbasi","year":"2007"},{"key":"b2-0110358","series-title":"Pain Physician","first-page":"185","article-title":"Epidural steroids in the management of chronic spinal pain: a systematic review","volume":"10","author":"Abdi","year":"2007"},{"key":"b3-0110358","series-title":"Reg Anesth","first-page":"149","article-title":"Complications associated with epidural steroid injections","volume":"21","author":"Abram","year":"1996"},{"key":"b4-0110358","series-title":"Anesthesiology","doi-asserted-by":"publisher","first-page":"701","DOI":"10.1097\/00000542-200503000-00048","article-title":"Epidural hematoma after epidural steroid injection in a patient withholding enoxaparin per guidelines","volume":"102","author":"Ain","year":"2005"},{"key":"b5-0110358","series-title":"Anesthesiology","doi-asserted-by":"publisher","first-page":"1558","DOI":"10.1097\/00000542-199911000-00065","article-title":"Caution in performing epidural injections in patients on several antiplatelet drugs","volume":"91","author":"Benzon","year":"1999"},{"key":"b6-0110358","series-title":"Ann Rheum Dis","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1136\/ard.2003.019349","article-title":"Incidence and prevalence of complaints of the neck and upper extremity in general practice","volume":"64","author":"Bot","year":"2005"},{"key":"b7-0110358","series-title":"Arch Phys Med Rehabil","doi-asserted-by":"publisher","first-page":"627","DOI":"10.1016\/S0003-9993(02)04862-1","article-title":"Complications of fluoroscopically guided interlaminar cervical epidural injections","volume":"84","author":"Botwin","year":"2003"},{"key":"b8-0110358","series-title":"Arch Phys Med Rehabil","doi-asserted-by":"publisher","first-page":"1045","DOI":"10.1053\/apmr.2000.7166","article-title":"Complications of fluoroscopically guided transforaminal lumbar epidural injections","volume":"81","author":"Botwin","year":"2000"},{"key":"b9-0110358","series-title":"Am J Phys Med Rehabil","doi-asserted-by":"publisher","first-page":"416","DOI":"10.1097\/00002060-200106000-00005","article-title":"Complications of fluoroscopically guided caudal epidural injections","volume":"80","author":"Botwin","year":"2001"},{"issue":"3 Suppl 1","key":"b10-0110358","series-title":"Arch Phys Med Rehabil","first-page":"S87","article-title":"Lumbosacral epidural steroid injections","volume":"81","author":"Cannon","year":"2000"},{"key":"b11-0110358","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"1634","DOI":"10.1056\/NEJM199706053362303","article-title":"Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus","volume":"336","author":"Carette","year":"1997"},{"key":"b12-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"1860","DOI":"10.1097\/00007632-199809010-00012","article-title":"The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults","volume":"23","author":"Cassidy","year":"1998"},{"key":"b13-0110358","series-title":"Curr Opin Cardiol","doi-asserted-by":"publisher","first-page":"612","DOI":"10.1097\/00001573-199409000-00017","article-title":"Low molecular weight heparins","volume":"9","author":"Cosmi","year":"1994"},{"key":"b14-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"1689","DOI":"10.1097\/00007632-199808010-00015","article-title":"The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults","volume":"23","author":"Cote","year":"1998"},{"key":"b15-0110358","series-title":"J Bone Joint Surg Am","doi-asserted-by":"publisher","first-page":"63","DOI":"10.2106\/00004623-198567010-00009","article-title":"The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study","volume":"67","author":"Cuckler","year":"1985"},{"key":"b16-0110358","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1016\/j.spinee.2007.09.009","article-title":"Evidence-informed management of chronic low back pain with epidural steroid injections","volume":"8","author":"DePalma","year":"2008"},{"key":"b17-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"S176","DOI":"10.1097\/00007632-199206001-00020","article-title":"Response to steroid and duration of radicular pain as predictors of surgical outcome","volume":"17","author":"Derby","year":"1992"},{"key":"b18-0110358","series-title":"J Am Geriatr Soc","doi-asserted-by":"publisher","first-page":"1702","DOI":"10.1046\/j.1532-5415.2003.51553.x","article-title":"Function and back symptoms in older adults","volume":"51","author":"Edmond","year":"2003"},{"key":"b19-0110358","series-title":"J Rheumatol","first-page":"220","article-title":"Prevalence of back symptoms in elders","volume":"27","author":"Edmond","year":"2000"},{"key":"b20-0110358","series-title":"Pain","doi-asserted-by":"publisher","first-page":"299","DOI":"10.1016\/S0304-3959(02)00138-0","article-title":"The course of chronic pain in the community: results of a 4-year follow-up study","volume":"99","author":"Elliott","year":"2002"},{"key":"b21-0110358","series-title":"J Neurosurg Anesthesiol","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1097\/00008506-200110000-00008","article-title":"Recovery after high-dose methylprednisolone and delayed evacuation: a case of spinal epidural hematoma","volume":"13","author":"Ghaly","year":"2001"},{"key":"b22-0110358","series-title":"Am J Public Health","doi-asserted-by":"publisher","first-page":"1029","DOI":"10.2105\/AJPH.89.7.1029","article-title":"Back pain prevalence in US industry and estimates of lost workdays","volume":"89","author":"Guo","year":"1999"},{"key":"b23-0110358","series-title":"Anaesthesia","first-page":"220","article-title":"Spinal haematoma following epidural analgesia. Report of a patient with ankylosing spondylitis and a bleeding diathesis","volume":"43","author":"Gustafsson","year":"1988"},{"key":"b24-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"877","DOI":"10.1097\/00007632-199804150-00008","article-title":"The effect of epidural injection of betamethasone or bupivacaine in a rat model of lumbar radiculopathy","volume":"23","author":"Hayashi","year":"1998"},{"key":"b25-0110358","series-title":"Semin Roentgenol","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1016\/j.ro.2003.10.010","article-title":"Epidural steroid injections","volume":"39","author":"Hession","year":"2004"},{"key":"b26-0110358","series-title":"Blood Coagul Fibrinolysis","doi-asserted-by":"publisher","first-page":"795","DOI":"10.1097\/00001721-199410000-00018","article-title":"Protamine neutralization of intravenous and subcutaneous low-molecular-weight heparin (tinzaparin, Logiparin). An experimental investigation in healthy volunteers","volume":"5","author":"Holst","year":"1994"},{"key":"b27-0110358","series-title":"Anesth Analg","doi-asserted-by":"publisher","first-page":"1691","DOI":"10.1097\/00000539-200212000-00041","article-title":"Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection","volume":"95","author":"Horlocker","year":"2002"},{"key":"b28-0110358","series-title":"Anesth Analg","doi-asserted-by":"publisher","first-page":"874","DOI":"10.1213\/00000539-199710000-00031","article-title":"Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management","volume":"85","author":"Horlocker","year":"1997"},{"key":"b29-0110358","series-title":"Reg Anesth Pain Med","first-page":"129","article-title":"Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management","volume":"23","author":"Horlocker","year":"1998"},{"key":"b30-0110358","series-title":"Reg Anesth Pain Med","first-page":"164","article-title":"Neuraxial block and low-molecular-weight heparin: balancing perioperative analgesia and thromboprophylaxis","volume":"23","author":"Horlocker","year":"1998"},{"key":"b31-0110358","series-title":"Reg Anesth Pain Med","first-page":"172","article-title":"Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation)","volume":"28","author":"Horlocker","year":"2003"},{"key":"b32-0110358","series-title":"Anesth Analg","first-page":"303","article-title":"Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia","volume":"80","author":"Horlocker","year":"1995"},{"key":"b33-0110358","series-title":"Pain","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1016\/j.pain.2005.05.030","article-title":"Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections","volume":"117","author":"Huntoon","year":"2005"},{"key":"b34-0110358","series-title":"Arch Phys Med Rehabil","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1016\/j.apmr.2004.02.018","article-title":"Complications and side effects of cervical and lumbosacral selective nerve root injections","volume":"86","author":"Huston","year":"2005"},{"key":"b35-0110358","series-title":"Anesth Analg","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1213\/01.ANE.0000143564.71765.30","article-title":"Epidural hematoma unrelated to combined spinal-epidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement","volume":"100","author":"Hyderally","year":"2005"},{"key":"b36-0110358","series-title":"Acta Anaesthesiol Scand","doi-asserted-by":"publisher","first-page":"335","DOI":"10.1111\/j.1399-6576.1990.tb03097.x","article-title":"Local corticosteroid application blocks transmission in normal nociceptive C-fibres","volume":"34","author":"Johansson","year":"1990"},{"key":"b37-0110358","series-title":"J Rheumatol","first-page":"1341","article-title":"Is chronic widespread pain a predictor of all-cause morbidity? A 3 year prospective population based study in family practice","volume":"32","author":"Kadam","year":"2005"},{"key":"b38-0110358","series-title":"Am J Clin Pathol","doi-asserted-by":"publisher","first-page":"642","DOI":"10.1093\/ajcp\/103.5.642","article-title":"Monitoring the anticoagulant effects of a low molecular weight heparin preparation. Correlation of assays in orthopedic surgery patients receiving ardeparin sodium for prophylaxis of deep venous thrombosis","volume":"103","author":"Kessler","year":"1995"},{"key":"b39-0110358","series-title":"Neurosurg Rev","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s10143-002-0224-y","article-title":"Spinal hematoma: a literature survey with meta-analysis of 613 patients","volume":"26","author":"Kreppel","year":"2003"},{"key":"b40-0110358","series-title":"J Clin Anesth","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1016\/j.jclinane.2004.08.012","article-title":"Subdural hematoma after atraumatic spinal","volume":"17","author":"Landman","year":"2005"},{"key":"b41-0110358","series-title":"J Gerontol A Biol Sci Med Sci","doi-asserted-by":"publisher","first-page":"M487","DOI":"10.1093\/gerona\/54.10.M487","article-title":"Low back pain and disability in older wom en: independent association with difficulty but not inability to perform daily activities","volume":"54","author":"Leveille","year":"1999"},{"key":"b42-0110358","series-title":"Thromb Haemost","doi-asserted-by":"publisher","first-page":"940","DOI":"10.1055\/s-0038-1651032","article-title":"The relationship between anti-factor Xa level and clinical outcome in patients receiving enoxaparine low molecular weight heparin to prevent deep vein thrombosis after hip replacement","volume":"62","author":"Levine","year":"1989"},{"key":"b43-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"1457","DOI":"10.1097\/00007632-199807010-00006","article-title":"A population-based study of spinal pain among 35\u201345-year-old individuals. Prevalence, sick leave, and health care use","volume":"23","author":"Linton","year":"1998"},{"key":"b44-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"1846","DOI":"10.1097\/01.brs.0000226022.05420.1f","article-title":"Prevalence and characteristics of upper or mid-back pain in Finnish men","volume":"31","author":"Niemelainen","year":"2006"},{"key":"b45-0110358","series-title":"Prog Neurobiol","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1016\/S0301-0082(00)00065-4","article-title":"Cauda equina syndrome","volume":"64","author":"Orendacova","year":"2001"},{"key":"b46-0110358","series-title":"J Manipulative Physiol Ther","doi-asserted-by":"publisher","first-page":"536","DOI":"10.1016\/j.jmpt.2007.07.005","article-title":"Acute intracranial subdural hematoma after epidural steroid injection: a case report","volume":"30","author":"Ozdemir","year":"2007"},{"key":"b47-0110358","series-title":"Spine","doi-asserted-by":"publisher","first-page":"E174","DOI":"10.1097\/00007632-200203150-00022","article-title":"Subdural hematoma after cervical epidural steroid injection","volume":"27","author":"Reitman","year":"2002"},{"key":"b48-0110358","series-title":"AANA J","first-page":"183","article-title":"Risk, benefits and complications of epidural steroid injections: a case report","volume":"75","author":"Snarr","year":"2007"},{"key":"b49-0110358","series-title":"Can J Anaesth","doi-asserted-by":"publisher","first-page":"R129","DOI":"10.1007\/BF03011675","article-title":"Impaired haemostasis and regional anaesthesia","volume":"43","author":"Stafford-Smith","year":"1996"},{"key":"b50-0110358","series-title":"Spine J","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1016\/j.spinee.2005.08.009","article-title":"Influence of needle-tip position on the incidence of immediate complications in 2,217 selective lumbar nerve root blocks","volume":"6","author":"Stalcup","year":"2006"},{"key":"b51-0110358","series-title":"Surg Neurol","doi-asserted-by":"publisher","first-page":"235","DOI":"10.1016\/S0090-3019(02)00639-0","article-title":"Epidural hematoma after epidural block: implications for its use in pain management","volume":"57","author":"Stoll","year":"2002"},{"key":"b52-0110358","series-title":"Br J Anaesth","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1093\/bja\/aei297","article-title":"Epidural haematoma after a combined spinal-epidural anaesthetic in a patient treated with clopidogrel and dalteparin","volume":"96","author":"Tam","year":"2006"},{"key":"b53-0110358","series-title":"Pain Pract","first-page":"59","article-title":"Vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections","volume":"9","author":"Trentman","year":"2008"},{"key":"b54-0110358","series-title":"Reg Anesth Pain Med","first-page":"178","article-title":"European practice guidelines: thromboembolism prophylaxis and regional anesthesia","volume":"23","author":"Tryba","year":"1998"},{"key":"b55-0110358","series-title":"Anesth Analg","first-page":"1165","article-title":"Anticoagulants and spinal-epidural anesthesia","volume":"79","author":"Vandermeulen","year":"1994"},{"key":"b56-0110358","series-title":"Reg Anesth","first-page":"149","article-title":"Complications of cervical epidural nerve blocks with steroids: a prospective study of 790 consecutive blocks","volume":"14","author":"Waldman","year":"1989"},{"key":"b57-0110358","series-title":"J Manipulative Physiol Ther","doi-asserted-by":"publisher","first-page":"238","DOI":"10.1016\/j.jmpt.2004.02.002","article-title":"Low back pain in Australian adults: prevalence and associated disability","volume":"27","author":"Walker","year":"2004"},{"key":"b58-0110358","series-title":"Practitioner","first-page":"53","article-title":"Chronic lumbosciatic syndrome treated by epidural injection and manipulation","volume":"209","author":"Warr","year":"1972"},{"key":"b59-0110358","series-title":"Anaesth Intensive Care","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1177\/0310057X9502300506","article-title":"A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica","volume":"23","author":"Watts","year":"1995"},{"key":"b60-0110358","series-title":"Pain","doi-asserted-by":"publisher","first-page":"197","DOI":"10.1016\/0304-3959(90)91162-C","article-title":"Epidural haematoma requiring surgical decompression following repeated cervical epidural steroid injections for chronic pain","volume":"42","author":"Williams","year":"1990"},{"key":"b61-0110358","series-title":"J Trauma","doi-asserted-by":"publisher","first-page":"558","DOI":"10.1097\/00005373-199803000-00029","article-title":"Spinal epidural hematoma and ankylosing spondylitis: case report and review of the literature","volume":"44","author":"Wu","year":"1998"},{"key":"b62-0110358","series-title":"Can J Anaesth","doi-asserted-by":"publisher","first-page":"1260","DOI":"10.1007\/BF03013437","article-title":"Epidural anaesthesia and spinal haematoma","volume":"43","author":"Wulf","year":"1996"},{"key":"b63-0110358","series-title":"Thromb Haemost","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1055\/s-0038-1649639","article-title":"Comparison of the nonspecific binding of unfractionated heparin and low molecular weight heparin (Enoxaparin) to plasma proteins","volume":"70","author":"Young","year":"1993"}],"container-title":["Journal of Neurosurgery: Spine"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/11\/3\/article-p358.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/11\/3\/article-p358.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/11\/3\/article-p358.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,15]],"date-time":"2023-04-15T21:38:25Z","timestamp":1681594705000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/11\/3\/article-p358.xml"}},"subtitle":["Case report"],"short-title":[],"issued":{"date-parts":[[2009,9]]},"references-count":63,"journal-issue":{"issue":"3"},"URL":"https:\/\/doi.org\/10.3171\/2009.3.spine0916","relation":{},"ISSN":["1547-5654"],"issn-type":[{"value":"1547-5654","type":"print"}],"subject":[],"published":{"date-parts":[[2009,9]]}}}