Reducing risk of spinal haematoma from spinal and epidural pain procedures

• Published in: Scandinavian journal of pain 2018-04, Vol.18 (2), p.129-150
• Main Authors: Breivik, Harald, Norum, Hilde, Fenger-Eriksen, Christian, Alahuhta, Seppo, Vigfússon, Gísli, Thomas, Owain, Lagerkranser, Michael
• Format: Article
• Language: English
• Subjects: Anestesi och intensivvård; Anesthesia, Epidural - adverse effects; Anesthesia, Spinal - adverse effects; Anesthesiology and Intensive Care; anticoagulants; Clinical Medicine; epidural analgesia; Hematoma - epidemiology; Hematoma - etiology; Hematoma - prevention & control; Humans; Klinisk medicin; Medical and Health Sciences; Medicin och hälsovetenskap; platelet inhibitors; postoperative complications; Postoperative Complications - epidemiology; Postoperative Complications - prevention & control; practise advisory; Risk; spinal analgesia; Spinal Cord Diseases - epidemiology; Spinal Cord Diseases - etiology; Spinal Cord Diseases - prevention & control; spinal haematoma
• ISSN: 1877-8860; 1877-8879
• DOI: 10.1515/sjpain-2018-0041

Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory. We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures. Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients' comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur. When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH. There is an on-going development of drugs for prevention of thromboembolic events following