Introduction: Epidural injections of steroid or anesthetic can be effective for chronic pain in appropriately selected patients, but severe neurosurgical complications have been rarely reported. The purpose of this study is to define the spectrum of complications that present to an academic neurosurgery service.

Methods: A prospectively maintained database of 27,000 neurosurgical admissions over 14 years were reviewed to identify all patients who had suffered major procedural complications, defined as a new symptom or neurological deficit definitively related to the procedure with evidence of radiological or pathological abnormality. A retrospective analysis of demographic and procedural features was performed.

Results: There were a total of 17 patients who had experienced major neurosurgical complications associated with epidural injections, accounting for 0.64% of all neurosurgical admissions. There were three broad categories of complication: hemorrhagic (n=11), infectious (n=4), and CSF-related (n=2). There was significantly greater association with a history of anticoagulation use among patients with hemorrhagic vs. nonhemorrhagic complications (p<0.01, Fisher’s exact test). Four patients who developed epidural hematoma had been managed in accordance with the 2014 ASRA guidelines, either after cessation of anticoagulation (n=2) or were taking aspirin only prior to the procedure (n=2). Four infections were identified, and none of the patients were treated with prophylactic antibiotics. The CSF-related cases consisted of diffuse pneumocephalus (n=1) and acutely symptomatic colloid cyst (n=1).

Conclusions: Major neurosurgical complications of epidural injections are distinctly rare but can be quite serious. A majority of these are hemorrhagic and associated with a history of therapeutic anticoagulation; non-hemorrhagic complications tend to be infectious or associated with altered CSF dynamics from inadvertent dural penetration. Prompt treatment of compressive epidural hematoma and abscess can be associated with good outcome.

Patient Care: 1) Improve awareness on rare injection complications 2) Identify patients at risk for rare complications 3) Improve surgeon counseling abilities on injections

Learning Objectives: By the conclusion of this session, participants should be able to: 1) define rare epidural injection complications 2) identify risk factors for occurrence 3) counsel patients on the inherent rare risk to this routine procedure

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