Epidural hematoma

[Aether2000]

Patient taking ASA 81mg/day long term for TIA history, stopped the ASA for 2 weeks prior to a thoracic epidural steroid injection approx T8 for "one sided back pain" with no referral of pain around the ribs. Resumed taking ASA same night as the epidural. Over the next few days developed increasing unilateral lower extremity weakness, numbness and tingling with balance issues, but no loss of bowel or bladder control. MRI demonstrated a T8 epidural hematoma with cord compression. The patient was scheduled for surgical decompression. Consideration: Have patients resume ASA at least a day after an ESI..... Or did it make any difference in this case?

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[needledox]

No difference. This is bad luck, likely an underlying coagulopathy

 

[thecentral09]

ASRA reccs are 24 hrs after needle comes out. That’s what I have done. No problems yet.
On another note why 2 weeks? 6-7 days should be sufficient

 

[soccrwz]

"Aspirin is rapidly absorbed from the gastrointestinal (GI) tract, with peak levels occurring approximately 30 minutes following ingestion, resulting in significant platelet inhibition at 1 hour.43,44 The peak plasma levels for enteric-coated ASA may be delayed until 3 to 4 hours after ingestion." From the ASRA guideline paper

Very interesting case, thanks for positing; Guidelines say restart 24 hours later. I've seen people who do SCS on ASA b/c cardiologist wont let them stop, pt agreed to proceed despite the risks.

Were they on an SSRI, or SNRI that may increase their bleeding risk? Overall bad luck

 

[Aether2000]

She was not taking SSRIs or SNRI, Vit E, Coenzyme Q, any other NSAIDs, antiplatelet, or anticoagulant medications. She presented to my hospital for surgery- I was her anesthesiologist for the procedure.

 

[needledox]

I typically jhave them restarted “the next day”. I’ll start saying 24 hours after procedure

 

[Orin]

She was not taking SSRIs or SNRI, Vit E, Coenzyme Q, any other NSAIDs, antiplatelet, or anticoagulant medications. She presented to my hospital for surgery- I was her anesthesiologist for the procedure.

What was her clinical bleeding like during the case?

What did the procedure note for the ESI document and do you have imaging to review?

Did you look at the MRI for the case and evaluate the levels for vessels near/adjacent to the target level?

 

[SSdoc33]

Hooo boy. Don't get Steve started on this.

Asa should never have been held to start with. Doesn't matter when it was restarted.

There is always a risk of a bleed, which is why we consent for that. I have never seen one after >10k epidurals, and I'm pretty liberal with injecting on blood thinners

 

[paindoc007]

Did you look at the MRI for the case and evaluate the levels for vessels near/adjacent to the target level?

Who the hell does that?

 

[painfree23]

The point here is the aspirin is irrelevant. Let’s stop focusing on that.

 

[clubdeac]

Yeah who holds ASA for neuraxial procedures? I thought the latest guidelines recommended against it? Am I missing something here?

 

[Orin]

Are you saying outliers shouldn't drive guidelines and practice parameters?

Regarding the imaging, it's easy to blame the aspirin, but it's more the needle than the drug, so I don't get why you wouldn't look at the pre/post MRI to see if there are vessels where that needle was, as they're clearly visible in many cases.

Was this a unilateral TF injection that tore a radicular artery? Was this a venous bleed? Was there blood outside the epidural space? Was it all ventral or dorsal?

We can do better than just blaming the aspirin and shrugging our shoulders about the patient specific risks

 

[jsaul]

the proceduralist must have been doing a lot of mucking around with a big needle. this has nothing to do with asa.
i have also done >10k interlaminers and TF's on thinners

 

[oreosandsake]

AV Malformation in the epidural space possible culprit.

 

[hyperalgesia]

Hooo boy. Don't get Steve started on this.

Asa should never have been held to start with. Doesn't matter when it was restarted.

There is always a risk of a bleed, which is why we consent for that. I have never seen one after >10k epidurals, and I'm pretty liberal with injecting on blood thinners

"For primary prevention, ASA should not be restarted for at least
24 hours following high-risk procedures and specific intermediate risk
procedures, including interlaminar cervical ESIs and stellate
ganglion blocks, where specific anatomical configurations
may increase the risk and consequences of procedural bleeding.
We recommend a delay because ASA rapidly and significantly
affects platelet function after ingestion. Aspirin also influences
thrombus stability and fibrinolysis. Clot stabilization probably
typically occurs at 8 hours." -Reg Anesth Pain Med 2018

 

[hyperalgesia]

Yeah who holds ASA for neuraxial procedures? I thought the latest guidelines recommended against it? Am I missing something here?

Recommended by ASRA in some cases.

 

[hyperalgesia]

Patient taking ASA 81mg/day long term for TIA history, stopped the ASA for 2 weeks prior to a thoracic epidural steroid injection approx T8 for "one sided back pain" with no referral of pain around the ribs. Resumed taking ASA same night as the epidural. Over the next few days developed increasing unilateral lower extremity weakness, numbness and tingling with balance issues, but no loss of bowel or bladder control. MRI demonstrated a T8 epidural hematoma with cord compression. The patient was scheduled for surgical decompression. Consideration: Have patients resume ASA at least a day after an ESI..... Or did it make any difference in this case?

It's comfortably within the grey area of the guidelines. Starting ASA the night of the procedure might have saved this pt from a catastrophic CVA...

 

[lobelsteve]

Guidelines from ASRA are idiotic and based on opinion. Kill more than harm.

Same case. But no aspirin. Now what? Just saw giant epidural hematoma after paddle implant and a second one after perc trial. One needed decompression cervical through lumbar spine. No thinners or ASA on either.

Only the needle knows.

 

[geauxg8rs]

Guidelines from ASRA are idiotic and based on opinion. Kill more than harm.

Same case. But no aspirin. Now what? Just saw giant epidural hematoma after paddle implant and a second one after perc trial. One needed decompression cervical through lumbar spine. No thinners or ASA on either.

Only the needle knows.

When I was an anesthesia resident the only
Epidural hematoma I ever saw was an otherwise healthy 40 yo
Male on no meds who presented for the surgery to decompress it. He never had a spinal procedure, hematoma was spontaneous

 

[painfree23]

the proceduralist must have been doing a lot of mucking around with a big needle. this has nothing to do with asa.
i have also done >10k interlaminers and TF's on thinners

U can’t assume this.

 

[hyperalgesia]

Well, we could argue about other cases but, in this particular case, the guidelines agree with what we are all saying.

 

[Orin]

U can’t assume this.

Why can you assume it's the aspirin and ignore the needle?

I'm still waiting to hear about the MR images. It's not rocket science if you're interested in understanding what happened.

 

[Aether2000]

We did not have MR images available to anesthesiology. The procedure was an interlaminar ESI.

 

[painfree23]

Why can you assume it's the aspirin and ignore the needle?

I'm still waiting to hear about the MR images. It's not rocket science if you're interested in understanding what happened.

What would “not-rocket-science” explanation be for a hematoma because of aspirin 81mg only happening in 1 in maybe 200,000 ?

 

[Orin]

What would “not-rocket-science” explanation be for a hematoma because of aspirin 81mg only happening in 1 in maybe 200,000 ?

I think we're looking for a reason to blame something because it can't be the needle, but I don't know if it's the drug or the needle or just the time of day. I know we've got imaging to look at though and we could see where the bleeder came from, if there was something there before the poke, etc.

It's easy to hide behind ASRA guidelines, but lets dive in on these weird cases to see before we just throw our hands up about the 81 mg of ASA.


Lets also dive in on some of the exceptions on the other side where people got away with it too though:

https://bjanaesthesia.org/article/S0007-0912(17)33645-0/fulltext

306 epidural catheters placed while on Plavix, 2/3rds of them also on ASA 81 mg.

"""Of the 306 patients, 217 were also on aspirin 81 mg daily which was continued through the perioperative period, and 238 received an intraoperative dose of i.v. heparin (5000 units) which was not reversed at the end of the surgery. We also identified three patients who had a bloody tap as a result of which the placement of an epidural catheter was aborted. None of the 306 patients who had an epidural catheter placed or the three patients who had a bloody tap developed any new neurological symptoms or other clinical evidence of epidural haematoma. None of these patients developed any new symptoms that required the performance of radiological studies such as MRI """

It's not the drug here. Lets look for the other thing