Cervical interlaminar epidural steroid injections (ESIs) are commonly performed as one part
of a multi-modal analgesic regimen in the management of upper extremity radicular pain.
Spinal epidural hematoma (SEH) is a rare complication with a reported incidence ranging from
1.38 in 10,000 to 1 in 190,000 epidurals. Current American Society of Regional Anesthesia
(ASRA), American Society of Interventional Pain Physicians (ASIPP), and the International Spine
Intervention Society (ISIS) recommendations are that non-steroidal anti-inflammatory drugs
(NSAIDs) do not need to be withheld prior to epidural anesthesia. We report a case wherein
intramuscular ketorolac and oral fluoxetine contributed to a SEH and tetraplegia following a
cervical interlaminar (ESI).
A 66 year-old woman with chronic renal insufficiency and neck pain radiating into her right upper
extremity presented for evaluation and was deemed an appropriate CESI candidate. Cervical
magnetic resonance imaging (MRI) revealed multi-level neuroforaminal stenosis and degenerative
intervertebral discs. Utilizing a loss of resistance to saline technique, an 18-gauge Tuohy-type
needle entered the epidural space at C6-7. After negative aspiration, 4 mL of saline with 80
mg of methyl-prednisolone was injected. Immediately thereafter, the patient reported significant
spasmodic-type localized neck pain with no neurologic status changes.
A decision was made to administer 30 mg intramuscular ketorolac as treatment for the spasmodictype pain. En route home, she developed a sudden onset of acute tetraplegia. She was brought to
the emergency department for evaluation including platelet and coagulation studies which were
normal. MRI demonstrated an epidural hematoma extending from C5 to T7. She underwent a
bilateral C5-T6 laminectomy with epidural hematoma evacuation and was discharged to an acute
inpatient rehabilitation hospital. Chronic renal insufficiency, spinal stenosis, female gender, and
increasing age have been identified as risk factors for SEH following epidural anesthesia. In the
present case, it is postulated that after the spinal vascular system was penetrated, hemostasis was
compromised by the combined antiplatelet effects of ketorolac, fluoxetine, fish oil, and vitamin E.
Although generally well tolerated, the role of ketorolac, a potent anti-platelet medication used
for pain relief in the peri-neuraxial intervention period, should be seriously scrutinized when other
analgesic options are readily available. Although the increased risk of bleeding for the alternative
medications are minimal, they are nevertheless well documented. Additionally, their additive
impairment on hemostasis has not been well characterized. Withholding NSAIDs, fluoxetine, fish
oil, and vitamin E in the peri-procedural period is relatively low risk and should be considered for
all patients with multiple risk factors for SEH.
Key words: Spontaneous epidural hematoma, ketorolac, cervical interlaminar epidural steroid
injection, fluoxetine, anti-platelet, neuraxial injection, perioperative pain
Treatment standards for spontaneous spinal epidural haematomas: management and main risk factors in era of anticoagulant/antiplatelet treatment
