Introduction: Chronic neck and back pain are prevalent conditions, cited as the most common reason for time missed from work. Interventional pain procedures such as epidural steroid and anesthetic injections have been used with good results in appropriately selected patients. Complications of epidural steroid injections include epidural hematoma, epidural infection/abscess, dural puncture and cerebrospinal leak, headache, seizure, neurologic damage, and death, with the incidence ranging from 1 in 10,000 to 1 in 200,000.

Methods: A prospectively maintained database of 12,000 charts were reviewed from 2001 to 2015 revealing 21 rare complications defined as operative epidural hematomas, abscesses, intramedullary hematomas, intracerebral hemorrhages, and cerebrospinal fluid leaks requiring repair that were admitted to the neurosurgical service at University Hospitals Case Medical Center. Four charts were excluded for incomplete data.

Results: We found 6 epidural hematomas requiring surgical intervention from 3 cervical and 3 lumbar epidural steroid injections (ESI). Four of these cases were on anticoagulation, 1 on antiplatelet medication, and only 2 out of 4 stopped medication prior to ESI. There were 4 epidural abscesses at injection sites requiring evacuation shortly all related to lumbar spine ESI. There were 2 intracerebral hemorrhages, one in the cerebellum and one in the pons directly after cervical ESI. One patient had a colloid cyst that became acutely symptomatic requiring a blood patch. We found three CSF leaks requiring surgical repair all related to lumbar injections. Lastly, we found two intramedullary hemorrhages from cervical ESI resulting in incomplete spinal cord injuries.

Conclusions: Chronic neck and back pain are prevalent and debilitating conditions in the aging population. Patients on blood thinning medications must be screened and managed judiciously prior to ESI. Patient selection and careful technique is critical to avoid these rare and serious complications.

Patient Care: By raising awareness of potential rare and serious complications related to ESI and how patient selection combined with judicious perioperative workup can minimize risks of serious adverse outcomes.

Learning Objectives: 1)Describe the importance in perioperative management of patients on anticoagulation or anitplatelet medications. 2)Discuss in small groups the potential rare and serious complications of ESI. 3)Identify how patient selection and careful technique can minimize rare complication occurrences.

References: REFERENCES 1. Anderberg L, Annertz M, Persson L, Brandt L, Säveland H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J 2007; 16: 321-8. 2. Benzon, H. T., et al. "Caution in Performing Epidural Injections in Patients on several Antiplatelet Drugs." Anesthesiology 91.5 (1999): 1558-9. Print. 3. Bohme, K., and M. Tryba. "Paraspinal Opioids and Pump Systems." Zeitschrift fur arztliche Fortbildung und Qualitatssicherung 92.1 (1998): 47-52. Print. 4. Brouwers, P. J., et al. "A Cervical Anterior Spinal Artery Syndrome After Diagnostic 0Blockade of the Right C6-Nerve Root." Pain 91.3 (2001): 397-9. Print. 5. Carragee, E. J., et al. "Treatment of Neck Pain: Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders." Journal of manipulative and physiological therapeutics 32.2 Suppl (2009): S176-93. Print. 6. Engquist, M., et al. "Surgery Versus Nonsurgical Treatment of Cervical Radiculopathy: A Prospective, Randomized Study Comparing Surgery Plus Physiotherapy with Physiotherapy Alone with a 2-Year Follow-Up." Spine 38.20 (2013): 1715-22. Print. 7. Fiebert, I. M. "An Overview of Functional Progressions in the Rehabilitation of Low Back Patients." Journal of back and musculoskeletal rehabilitation 3.4 (1993): 36-49. Print. 8. Ghaly, R. F. "Recovery After High-Dose Methylprednisolone and Delayed Evacuation: A Case of Spinal Epidural Hematoma." Journal of neurosurgical anesthesiology 13.4 (2001): 323-8. Print. 9. Heckmann, J. G., et al. "Transient Tetraplegia After Cervical Facet Joint Injection for Chronic Neck Pain Administered without Imaging Guidance." Clinical neurology and neurosurgery 108.7 (2006): 709-11. Print. 10. Hirpara, K. M., et al. "Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis." Advances in orthopedics 2012 (2012): 294857. Print. 11. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976). 1998 Oct 1;23(19):2137-42; discussion 2141-2. 12. Huston, C. W. "Cervical Epidural Steroid Injections in the Management of Cervical Radiculitis: Interlaminar Versus Transforaminal. A Review." Current reviews in musculoskeletal medicine 2.1 (2009): 30-42. Print. 13. Kim, T. S., et al. "Air Bubbles Mimic Disc Herniation in MRI After Cervical Epidural Block." The Korean journal of pain 23.3 (2010): 202-6. Print. 14. Lee, J. H., et al. "Spinal Cord Injury Produced by Direct Damage during Cervical Transforaminal Epidural Injection." Regional anesthesia and pain medicine 33.4 (2008): 377-9. Print. 15. Linn, A. J., C. Desilva, and C. Peeters-Asdourian. "Thromboembolic Stroke: A Rare Complication Associated with Peri-Procedural Management of an Epidural Steroid Injection." Pain physician 12.1 (2009): 159-62. Print. 16. Malhotra, G., A. Abbasi, and M. Rhee. "Complications of Transforaminal Cervical Epidural Steroid Injections." Spine 34.7 (2009): 731-9. Print. 17. Manchikanti, L., et al. "Complications of Fluoroscopically Directed Facet Joint Nerve Blocks: A Prospective Evaluation of 7,500 Episodes with 43,000 Nerve Blocks." Pain physician 15.2 (2012): E143-50. Print. 18. Manchikanti, L., et al. "Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy." Pain physician 16.2 Suppl (2013): SE261-318. Print. 19. Manchikanti, L., et al. "Two-Year Follow-Up Results of Fluoroscopic Cervical Epidural Injections in Chronic Axial Or Discogenic Neck Pain: A Randomized, Double-Blind, Controlled Trial." International journal of medical sciences 11.4 (2014): 309-20. Print. 20. Mehta, S., A. A. Khalil, and A. Alshekhlee. "Air Myelopathy Following a Cervical Epidural Injection." Pain medicine (Malden, Mass.) 11.11 (2010): 1678-9. Print. 21. Moon JY, Lee PB, Hahm FS, Kim YC, Choi JB. Cervical epidural pressure measurement: comparison in the prone and sitting positions. Anesthesiology 113.3 (2010): 666-71. 22. Murphy, D. R., and E. L. Hurwitz. "Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain." Chiropractic & manual therapies 19.1 (2011): 19,709X-19-19. Print. 23. Nikolaidis, I., et al. "Surgery for Cervical Radiculopathy Or Myelopathy." The Cochrane database of systematic reviews (1):CD001466. doi.1 (2010): CD001466. Print. 24. Nolan, R. B., D. A. Masneri, and D. Pesce. "Pneumocephalus After Epidural Injections." BMJ case reports 2009 (2009): bcr2006044412. Print. 25. Rathmell JP, Kehlet H. Do we have the tools to prevent phantom limb pain? Anesthesiology 114.5 (2011): 1021-4 26. Reitman, C. A., and W. Watters 3rd. "Subdural Hematoma After Cervical Epidural Steroid Injection." Spine 27.6 (2002): E174-6. Print. 27. Schoenfeld AJ, George AA, Bader JO, Caram PM. Incidence and Epidemiology of Cervical Radiculopathy in the United States Military: 2000 to 2009. J Spinal Disord Tech 2011 Mar 21 28. Shanthanna, H., and J. Park. "Acute Epidural Haematoma Following Epidural Steroid Injection in a Patient with Spinal Stenosis." Anaesthesia 66.9 (2011): 837-9. Print. 29. Stav A, Ovadia L, Sternberg A, Kaadan M, Weksler N. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand 1993; 37: 562-6. 30. Stoll, A., and M. Sanchez. "Epidural Hematoma After Epidural Block: Implications for its use in Pain Management." Surgical neurology 57.4 (2002): 235-40. Print. 31. Wallace MA. et al., Complications of Cervical Selective Nerve Root Blocks Performed with Fluoroscopic Guidance Am. J. Roentgenol., May 2007; 188: 1218 - 1221. 32. Williams, K. N., A. Jackowski, and P. J. Evans. "Epidural Haematoma Requiring Surgical Decompression Following Repeated Cervical Epidural Steroid Injections for Chronic Pain." Pain 42.2 (1990): 197-9. Print. 33. Wulf, H. "Epidural Anaesthesia and Spinal Haematoma." Canadian journal of anaesthesia = Journal canadien d'anesthesie 43.12 (1996): 1260-71. Print. 34. Xu, R., et al. "Epidural Steroid Injection Resulting in Epidural Hematoma in a Patient Despite Strict Adherence to Anticoagulation Guidelines." Journal of neurosurgery.Spine 11.3 (2009): 358-64. Print. 35. Yang, Y. W., et al. "Bacterial Infection in Deep Paraspinal Muscles in a Parturient Following Epidural Analgesia." Acta anaesthesiologica Taiwanica : official journal of the Taiwan Society of Anesthesiologists 49.2 (2011): 75-8. Print.