Can Lumbar Epidurals Cause My Hiv to Become Detectable Again

i Introduction

Lower back hurting is one of the virtually prevalent conditions that patients endure from. Among the causes of lower back pain, radiculopathy is one of the well-nigh common, comprising around 9.9% to 25% of cases.^[1] Radiculopathy occurs through nerve irritation and nervus root inflammation due to herniated nucleus pulposus, lumbar foraminal stenosis, and other disorders. Radiculopathy pain is located at the lower back and buttock and radiates to the legs.^[two] Many studies have shown that injecting advisable drugs such every bit local anesthetics or steroids into the epidural space can be helpful for radiculopathy hurting relief and control. Lumbar epidural injection methods consist of 3 approaches: interlaminar, caudal canal, and transforaminal.^[3] The transforaminal approach method, in detail, is increasingly and widely performed present. Accordingly, transforaminal epidural steroid injection (TFESI) has been considered a better method of injecting drugs into the ventral portion of the epidural infinite compared to other methods, and it has been shown that injecting drugs into the ventral portion of epidural space is more than beneficial for pain relief and control.^[four,5] However, one of the devastating complications of TFESI is epidural hematoma, which can lead to serious neurologic sequelae and can occur even though it is performed with appropriate skill nether fluoroscopic guidance.^[6] The prevalence of epidural hematoma later epidural anesthesia is around 1/150,000, but prevalence after TFESI has not been studied.^[vii] In hurting practice, spinal hematoma complication is rare after epidural injection, and there are few example reports where epidural hematoma occurs elsewhere in the injection site. In this case, a patient developed acute severe back pain and lower extremity motor deficits due to an epidural hematoma located at a level distant from the injection site.

2 Case report

The patient, an 82-year-onetime Asian man, was admitted with lower back pain and bilateral buttock pain. Lumbar spinal stenosis at L1-L3 was constitute on the magnetic resonance imaging (MRI) taken at some other hospital (Fig. 1). On physical examination, the patients' bilateral lower extremity motor and sensory functions were intact, but lower back hurting and bilateral buttock pain were astringent (measured as 4 points on the pain numeric rating scale) so conservative treatment and TFESI were scheduled for pain control.

Effigy i:

Lumbar sagittal T2 weighted magnetic resonance imaging showing lumbar spinal stenosis at L1-L3 (arrows).

The patient had undergone posterior lumbar interbody fusion at L3-L5 due to spinal stenosis in 2012 and was diagnosed with an L1-level pinch fracture in 2017 for which he received bourgeois treatment and L2-level root blocks several times. He also had a previous medical history of blazon 2 diabetes mellitus and hypertension but was non taking any medications. The patient's blood pressure was stable and the average of the blood force per unit area measurements taken on admission was 140/lxx mm Hg.

Laboratory findings later on admission included: normal electrolyte levels, hematocrit 41.half dozen%, platelet count 340,000/mmⁱⁱⁱ, prothrombin time xi.3 seconds, and activated fractional thromboplastin time 30.0 seconds.

The TFESI was performed at the correct intervertebral foramen between L2 and L3 under fluoroscopic guidance. Afterwards sterilizing the pare, local anesthesia was practical to the expanse with three mL of 1% lidocaine. In the lateral oblique fluoroscopic images, a xx-approximate brusque bevel nerve cake needle was placed at the L2 lumbar pedicle junior margin (vi o'clock position of the pedicle). And so the needle was slightly avant-garde in the lateral view and placed in the dorsal periosteum of the vertebral torso. We confirmed that the needle was placed in the epidural space by using 2 mL of contrast amanuensis (Figs. 2 and 3). A vi mL mixture of 10 mg of 0.5% bupivacaine (v mg/mL), 3 mL of normal saline, and 5 mg of dexamethasone (5 mg/mL) was injected slowly; we observed no abnormalities during the procedure. After confirming that in that location were no complications, we moved the patient from the recovery room to the ward. The patient's back pain was slightly improved initially, but the next morning, the patient underwent emergency MRI due to severe correct lower back hurting and bilateral diffuse lower extremity motor deficit with motor role grade 4 on a 5-point severity scale.

Figure 2:

Fluoroscopic anteroposterior view showing dissimilarity spreading from L1 to L3 epidural space during transforaminal epidural injection.

Figure three:

Fluoroscopic lateral view showing contrast spreading from L1 to L3 epidural space during transforaminal epidural injection.

Lumbar spine MRI showed a fluid collection at the posterior epidural infinite from the T11 to L1 level with central canal stenosis (Figs. four and 5). Surgical evacuation was performed that evening for a suspected epidural hematoma.

Figure 4:

Lumbar sagittal T2 weighted magnetic resonance imaging showing heterogeneous high signal intensity (arrows) at the ventral epidural space spreading from T11 to L1.

Figure 5:

Lumbar axial T2 weighted magnetic resonance imaging showing heterogeneous signal intensity (pointer) at T12.

Nether the full general anesthesia, the patient lay in the prone position and an incision was made over the spinous processes from T12 to L2. Laminectomy was performed bilaterally at the T12-L2 level due to hematoma and preexisting spinal stenosis. At that place was a rubbery, hard, clotted hematoma mass over the thecal sac from T12 to L1 (Fig. 6). The entire compressing hematoma mass was removed. In that location was continuing bleeding at the proximal T12 body, posterior side, which was considered the origin of the epidural hematoma. After surgery, the sudden back pain dramatically disappeared. Two weeks later on, the patient was discharged without any other symptoms.

Figure half-dozen:

Intraoperative photograph showing a clotted mass of nighttime brown hematoma at the T12 epidural space (pointer).

3 Discussion

Known side effects of TFESI include infections, hematoma, intravascular injections, nerve trauma, dural puncture, and air embolism. The prevalence of epidural hematoma after TFESI has not yet been established.^[8]

1 of the causes of epidural hematoma is vessel injury near the foramen due to direct needle injury.^[8] Vessel injury, which can increment the likelihood of intravascular drug delivery, can lead to bleeding and hematoma formation. This run a risk is higher in patients taking anticoagulants and in patients with inherited and acquired coagulation disorders, but information technology tin can occur in patients without any history of medication utilise or other run a risk factors; therefore, considerable caution is required during the procedure.^[9]

One of the claret vessels that tin be damaged during TFESI procedures is the internal vertebral venous plexus.^[six] This plexus, also referred to as Batson's plexus, encircles the spinal canal. Its inductive part is located in the inductive epidural space and consists of two interconnected veins extending longitudinally through the back of the intervertebral disc and vertebral bodies. These veins are located behind the posterior longitudinal ligament; the closer the needle approaches to the anterior epidural space, the greater the likelihood of vessel damage by needle puncture.^[6] Some other vessel that tin be damaged by straight needle injury is the radicular artery that runs alongside the spinal nerve root. The radicular arteries derive from the lumbar arteries originating from branches of the aorta and supply blood to the spinal fretfulness and nervus roots.^[10] The radicular artery enters the intervertebral foramen forth the nerve root; the probability that the artery is in the upper part of the foramen is around two-fold greater than the probability of information technology being in the lower part, and in that location is an increased take chances of damaging the vessel during needle entry through the "safe triangle."^[xi]

In addition to directly needle injury, the crusade of epidural hematoma may relate to vessel damage due to increased pressure in the epidural space. In a case described by Shanthanna and Park,^[12] epidural hematoma occurred at the T10-T12 level after epidural block at L3-L4 level. They suggested the possibility of vessel rupture due to the force per unit area of drug injection as an caption for the epidural hematoma occurring somewhat distant from the cake point. In patients with spinal stenosis, the epidural pressure is increased past the narrow spinal culvert. If pressure is applied during drug injection, the strength of the thinning vessel wall of the venous plexus is exceeded, resulting in hematoma. There accept been other reported cases where hematoma is thought to effect from a similar cause. In the instance reported past Choi et al,^[thirteen] epidural hematoma occurred at the L2-L4 level afterwards caudal block. In the cases reported past Gungor and Arier,^[xiv] postal service-TFESI contralateral epidural hematoma occurred in the direction of injection. In the higher up 3 cases, warfarin or antiplatelet drugs were implicated but in our case, the patient was not taking any anticoagulant or antiplatelet drugs. The utilise of anticoagulants or antiplatelet drugs increases the gamble of epidural hematoma. According to Vandermeulen et al,^[15] in 42 spinal hematomas in 61 patients, an associated hemostatic abnormality was identified.

We believe that the reason for the hematoma in our instance was the increasing pressure in the epidural space rather than direct needle injury. The needle entered the correct intervertebral foramen betwixt L2 and L3 but the epidural hematoma was located at L1-T11 and the majority of the hematoma was in the posterior T12 epidural space. Also, the origin of the epidural hematoma detected during surgery was suspected to be posterior to the 12th thoracic body. In a study reported by Usubiaga et al,^[16] the pressure in the epidural space increased from −1 to −10 cmH₂O before injection to a maximum of 65 cmH₂O after injection of 10 mL of two% lidocaine into the epidural infinite. The pressure level was college in the elderly than in the younger patients and the loftier epidural pressure was maintained until ii minutes after injection. Furthermore, in the review by Kreppel et al,^[17] 86 of 613 spinal hematomas (14%) were caused past coughing, defecation, or sex, which elementary actions increased the force per unit area in the epidural space.

In conclusion, a clinician performing TFESI should always be mindful of the possibility of epidural hematoma, because it can be fatal or cause permanent damage to the patient. It should be considered that this can occur due to increased pressure at the time of drug injection, even if there is no indication of bleeding or no history of taking medications such as anticoagulant drugs. Proceed equally slowly as possible when injecting the drug, and if resistance is felt, do not inject with force considering of the possibility of hematoma due to increasing epidural pressure particularly extremely care when acquit out a patient who is expected to high epidural pressure level such every bit an elderly or a patient with severe spinal stenosis. In addition, if the patient complains of astringent pain subsequently a TFESI procedure or has a specific symptom, the possibility of epidural hematoma should be evaluated by MRI without delay.

Author contributions

Conceptualization: Sang-in Kim, Yong-Hyun Cho.

Supervision: Dong-Hyun Lee, Sun-Hee Kim, Yong-Hyun Cho.

Visualization: Sang-in Kim, Sun-Hee Kim.

Writing – original typhoon: Sang-in Kim.

Writing – review & editing: Yong-Hyun Cho.

References

[1]. Konstantinou Thousand, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976) 2008;33:2464–72.

• Cited Here

[2]. Ropper AH, Zafonte RD. Sciatica. North Engl J Med 2015;372:1240–8.

• Cited Here

[3]. Cohen SP, Bicket MC, Jamison D, et al. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med 2013;38:175–200.

• Cited Here

[iv]. Schaufele MK, Hatch L, Jones Due west. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Dr. 2006;9:361–6.

• Cited Here

[five]. Roberts ST, Willick SE, Rho ME, et al. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R 2009;i:657–68.

• Cited Here

[six]. Desai MJ, Dua S. Perineural hematoma following lumbar transforaminal steroid injection causing acute-on-chronic lumbar radiculopathy: a case report. Hurting Pract 2014;14:271–seven.

• Cited Here

[7]. Moen V, Dahlgren N, Irestedt L. Severe neurological complications afterward primal neuraxial blockages in Sweden 1990 – 1999. Anesthesiology 2004;101:950–ix.

• Cited Here

[8]. Goodman BS, Posecion LWF, Mallempati S, et al. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Curr Rev Musculoskelet Med 2008;1:212–22.

• Cited Hither

[9]. Windsor RE, Storm South, Sugar R. Prevention and management of complications resulting from common spinal injections. Pain Physician 2003;6:473–83.

• Cited Here

[x]. Mandell JC, Czuczman GJ, Gaviola GC, et al. The lumbar neural foramen and transforaminal epidural steroid injections: An anatomic review with key safety considerations in planning the percutaneous approach. AJR Am J Roentgenol 2017;209:W26–35.

• Cited Here

[xi]. Melissano K, Chiesa R. Advances in imaging of the spinal cord vascular supply and its relationship with paraplegia subsequently aortic interventions. A review. Eur J Vasc Endovasc Surg 2009;38:567–77.

• Cited Hither

[12]. Shanthanna H, Park J. Acute epidural haematoma post-obit epidural steroid injection in a patient with spinal stenosis. Anaesthesia 2011;66:837–9.

• Cited Hither

[13]. Choi JJ, Chang YJ, Jung WS, et al. Discordant lumbar epidural hematoma subsequently caudal steroid injection: a example study (CARE-compliant). Medicine (Baltimore) 2017;96:e7127.

• Cited Hither

[xiv]. Gungor S, Aiyer R. Epidural hematoma development contralateral to dura afterward lumbar transforaminal epidural steroid injection. Hurting Manag 2017;7:367–75.

• Cited Here

[xv]. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165–77.

• Cited Here

[16]. Usubiaga JE, Wikinski JA, Usubiaga LE. Epidural pressure and its relation to spread of anesthetic solutions in epidural infinite. Anesth Analg 1967;46:440–half dozen.

• Cited Hither

[17]. Kreppel D, Antoniadis Grand, Seeling West. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1–49.

• Cited Here

Keywords:

epidural injections; lower back pain; spinal epidural hematoma; spinal stenosis

Copyright © 2019 the Author(south). Published by Wolters Kluwer Health, Inc.

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Source: https://journals.lww.com/md-journal/fulltext/2019/07260/spinal_epidural_hematoma_occurring_at_a_distance.95.aspx

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