Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

See all formats and pricing
More options …
Volume 15, Issue 1


Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors

Michael Lagerkranser
  • Corresponding author
  • Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm Stockholm, Sweden
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2017-04-01 | DOI: https://doi.org/10.1016/j.sjpain.2016.11.008



Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.


MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.


Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.

Conclusions and implications

The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.

Keywords: Anaesthesia; Regional; Haematoma; Spinal; Complication; Anticoagulants


  • [1]

    Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–99. Anesthesiology 2004;101:950–9.Google Scholar

  • [2]

    Landoni G, Isella F, Greco M, Zangrillo A, Royse CF. Benefits and risks of epidural analgesia in cardiac surgery. Br J Anaesth 2015;115:25–32.Google Scholar

  • [3]

    Schmidt A, Nolte H. Subdural and epidural hematomas following epidural anesthesia. A literature review. Anaesthesist 1992;41:276–84.Google Scholar

  • [4]

    Vandermeulen E, van Aken H, Vermylen J. Anticoagulants and spinal–epidural anesthesia. Anesth Analg 1994;79:1165–77.Google Scholar

  • [5]

    Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth 1996;43:1260–71.Google Scholar

  • [6]

    Horlocker TT, Heit JA. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 1997;85:874–85.Google Scholar

  • [7]

    Tryba M. European practice guidelines: thromboembolism prophylaxis and regional anaesthesia. Reg Anesth Pain Med 1998;23:178–82.Google Scholar

  • [8]

    Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010;54:16–41.Google Scholar

  • [9]

    Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesth 2010;27:999–1015.Google Scholar

  • [10]

    Butterworth JF. Case reports: unstylish but still useful sources of clinical information (editorial). Reg Anesth Pain Med 2009;34:187–8.Google Scholar

  • [11]

    Bent U, Gniffke S, Reinbold WD. Epidurales hämatom nach single shotepiduralanästhesie. An epidural haematoma following single shot epidural anesthesia. Anaesthesist 1994;43:245–8.Google Scholar

  • [12]

    Ganjoo P, Singh AK, Mishra VK, Singh PK, Bannerjee D. Postblock epidural haematoma causing paraplegia. Reg Anesth 1994;19:62–5.Google Scholar

  • [13]

    Gerlif C, Myrtue GS. Atypical site of epidural hematoma – after epidural analgesia. Ugeskr Laeger 1994;156:7231–2.Google Scholar

  • [14]

    Nicholson A. Painless epidural haematoma. Anaesth Intensive Care 1994;22:607–10.Google Scholar

  • [15]

    Bougher RJ, Ramage D. Spinal subdural haematoma following combined spinal–epidural anaesthesia. Anaesth Intensive Care 1995;23:111–3.Google Scholar

  • [16]

    Dahlgren N, Törnebrandt K. Neurological complications after anaesthesia. A follow-up of 18000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand 1995;39:872–80.Google Scholar

  • [17]

    Hartigan JD. Dangerous sequelae of epidural anaesthesia in geriatrics. Nebr Med J 1995;80:80–2.Google Scholar

  • [18]

    Morisaki H, Doi J, Ochiai R, Takeda J, Fukushima K. Epidural hematoma after epidural anesthesia in a patient with hepatic cirrhosis. Anesth Analg 1995;80:1033–5.Google Scholar

  • [19]

    Rainov NG, Heidecke V, Burkert WL. Spinal epidural hematoma. Report of a case and review of the literature. Neurosurg Rev 1995;18:53–60.Google Scholar

  • [20]

    Sternlo JE, Hybbinette CH. Spinal subdural bleeding after attempted epidural and subsequent spinal anaesthesia in a patient on thromboprophylaxis with low molecular weight heparin. Acta Anaesthesiol Scand 1995;39: 557–9.Google Scholar

  • [21]

    Badenhorst CH. Epidural hematoma after epidural pain control and concomitant postoperative anticoagulation. Reg Anesth 1996;21:272–3.Google Scholar

  • [22]

    Barontini F, Conti P, Marello G, Maurri S. Major neurological sequelae of lumbar epidural anesthesia. Report of three cases. Ital J Neurol Sci 1996;17:333–9.Google Scholar

  • [23]

    Bartoli F, Barbagli R, Rucci F. Anterior epidural haematoma following sub-arachnoid block. Can J Anaesth 1996;43:94.Google Scholar

  • [24]

    Hynson JM, Katz JA, Bueff HU. Epidural hematoma associated with enoxaparin. Anesth Analg 1996;82:1072–5.Google Scholar

  • [25]

    Likar R, Mathiaschitz K, Spendel M, Krumpholz R, Martin E. Akutes spinales subduralhämatom nach spinalaästesiversuch. Anaesthesist 1996;45:66–9.Google Scholar

  • [26]

    Martinez-Palli G, Sala-Blanch X, Salvadó E, Acosta M, Nalda MA. Epidural hematoma after epidural anesthesia in a patient with peripheral vascular disease. Case report. Reg Anesth 1996;21:342–6.Google Scholar

  • [27]

    Pryle BJ, Carter JA, Cadoux-Hudson T. Delayed paraplegia following spinal anaesthesia. Anaesthesia 1996;51:263–5.Google Scholar

  • [28]

    Rabito SF, Ahmed S, Feinstein L, Winnie AP. Intrathecal bleeding after the intraoperative use of heparin and urokinase during continuous spinal anesthesia. Anesth Analg 1996;82:409–11.Google Scholar

  • [29]

    Allen D, Dahlgren N, Nellgård B. Risks and recommendation in Bechterew disease. Paraparesis after epidural anesthesia. Lakartidningen 1997;94:4771–4.Google Scholar

  • [30]

    Aromaa U, Lahdensuu M, Cozanitis DA. Severe complications associated with epidural and spinal anaesthesia in Finland 1987–1993. A study based on patient insurance claims. Acta Anaesthesiol Scand 1997;41:445–52.Google Scholar

  • [31]

    Gerancher JC, Waterer R, Middleton J. Transient paraparesis after postdural puncture spinal hematoma in a patient receiving ketorolac. Anesthesiology 1997;86:490–4.Google Scholar

  • [32]

    Harvey SC, Roland PJ, Curé JK, Cuddy BC, O’Neil MG. Spinal epidural hematoma detected by lumbar epidural puncture. Anesth Analg 1997;84:1136–9.Google Scholar

  • [33]

    Porterfield WR, Wu CL. Epidural hematoma in an ambulatory surgical patient. J Clin Anesth 1997;9:74–7.Google Scholar

  • [34]

    Wood GG, Jacka MJ. Spinal hematoma following spinal anesthesia in a patient with spina bifida occulta. Anesthesiology 1997;87:983–4.Google Scholar

  • [35]

    Cabitza P, Parrini M. Slow-onset subdural hematoma, evolving into paraplegia, after attempted spinal anesthesia – a case report. Acta Orthop Scand 1998;69:650–2.Google Scholar

  • [36]

    Christensen PH, Johnstad B. Alvorlig neurologisk sekvele i tilslutning til spinal- og epiduralbedövelse. Tidsskr Nor Laegeforen 1998;118:244–6.Google Scholar

  • [37]

    Helland S, Berg-Johnsen J, Heier T, Nakstad PH. Intraspinal blødning etter torakal epidural smertebehandling. Tidsskr Nor Lægeforen 1998;118:241–4.Google Scholar

  • [38]

    Skilton RWH, Justice W. Epidural haematoma following anticoagulant treatment in a patient with an indwelling epidural catheter. Anaesthesia 1998;53:691–5.Google Scholar

  • [39]

    Wildförster U, Schregel W, Harders A. Delayed lumbar epidural hematoma. Discussion of the risk factors: hypertension, anticoagulation and spinal anesthesia. Anästhesiol Intensivmed Notfallmed Schmertzther 1998;33:517–20.Google Scholar

  • [40]

    Woolson ST, Robinson RK, Khan NQ, Rogers BS, Maloney JM. Deep venous thrombosis prophylaxis for knee replacement. Am J Orthop 1998;27:299–304.Google Scholar

  • [41]

    Basta M, Sloan P. Epidural hematoma following epidural catheter placement in a patient with chronic renal failure. Can J Anesth 1999;46:271–4.Google Scholar

  • [42]

    Domenicucci M, Ramieri A, Ciapetta P, Delfini R. Nontraumatic acute spinal subdural hematoma. Report of five cases and review of the literature. J Neurosurg (Spine 1) 1999;91:65–73.Google Scholar

  • [43]

    Goyal A, Dua R, Singh D, Kumar S. Spinal subarachnoid haematoma following lumbar puncture. Neurol India 1999;47:339–40.Google Scholar

  • [44]

    Pedraza Gutiérrez S, Coll Masfarré S, Castañ o Duque CH, Suescún M, Rovira Cañ ellas A. Hyperacute spinal subdural haematoma as a complication of lumbar spinal anaesthesia: MRI. Neuroradiology 1999;41:910–4.Google Scholar

  • [45]

    Yin B, Barratt SM, Power I, Percy J. Epidural haematoma after removal of an epidural catheter in a patient receiving high-dose enoxaparin. Br J Anaesth 1999;82:288–90.Google Scholar

  • [46]

    Yuen TST, Kua JSW, Tan IKS. Spinal haematoma following epidural anaesthesia in a patient with eclampsia. Anaesthesia 1999;54:350–71.Google Scholar

  • [47]

    Osmani O, Afeiche N, Lakkis S. Paraplegia after epidural anesthesia in a patient with peripheral vascular disease: case report and review of the literature with a description of an original technique for hematoma evacuation. J Spinal Disord 2000;13:85–7.Google Scholar

  • [48]

    Ousname ML, Fleyfel M, Vallet B. Epidural hematoma after catheter removal. Anesth Analg 2000;90:1246–51.Google Scholar

  • [49]

    Sandhu H, Morley-Foster P, Spadafora S. Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis. Reg Anesth Pain Med 2000;25:72–5.Google Scholar

  • [50]

    Stroud CC, Markel D, Sidhu K. Complete paraplegia as a result of regional anesthesia. J Arthroplasty 2000;15:1064–7.Google Scholar

  • [51]

    Esler MD, Durbridge J, Kirby S. Epidural haematoma after dural puncture in a parturient with neurofibromatosis. Br J Anaesth 2001;87:932–4.Google Scholar

  • [52]

    Ghaly RF. Recovery after high-dose methylprednisolone and delayed evacuation. J Neurosurg Anesth 2001;13:323–8.Google Scholar

  • [53]

    Litz RJ, Hübler M, Koch T, Albrecht M. Spinal–epidural hematoma following epidural anesthesia in the presence of antiplatelet and heparin therapy. Anesthesiology 2001;95:1031–3.Google Scholar

  • [54]

    Pánek V. Epidural haematoma and timing of heparin prophylaxis. Anaesthesia 2001;56:811–2.Google Scholar

  • [55]

    Siddiqui MN, Ranasinghe JS, Siddiqui S. Epidural hematoma after epidural steroid injection: a possible association with use of pentosan polysulfate sodium. Anesthesiology 2001;95:1307.Google Scholar

  • [56]

    Gilbert A, Owens BD, Mulroy MF. Epidural hematoma after outpatient epidural anesthesia. Anesth Analg 2002;94:77–8.Google Scholar

  • [57]

    Herbstreit F, Kienbaum P, Merguet P, Peters J. Conservative treatment of paraplegia after removal of an epidural catheter during low-molecular-weight heparin treatment. Anesthesiology 2002;97:733.Google Scholar

  • [58]

    Inoue K, Yokoyama M, Nakatsuka H, Goto K. Spontaneous resolution of epidural hematoma after continuous epidural analgesia in a patient without bleeding tendency. Anesthesiology 2002;97:735–7.Google Scholar

  • [59]

    Jaeger M, Rickels E, Schmidt A, Samii M, Blömer U. Lumbar ependymoma presenting with paraplegia following attempted spinal anaesthesia. Br J Anaesth 2002;88:438–40.Google Scholar

  • [60]

    Pay LL, Chiu JW, Thomas E. Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis. Acta Anaesthesiol Scand 2002;46:217–20.Google Scholar

  • [61]

    Persson J, Flisberg P, Lundberg J. Thoracic epidural anaesthesia and epidural haematoma. Acta Anaesthesiol Scand 2002;46:1171–4.Google Scholar

  • [62]

    Reitman CA, Watters W. Subdural hematoma after cervical epidural steroid injection. Spine 2002:E174–6.Google Scholar

  • [63]

    Stoll A, Sanchez M. Epidural hematoma after epidural block: implications for its use in pain management. Surg Neurol 2002;57:235–40.Google Scholar

  • [64]

    Drogosch E, Perneczky A, Berhardt A. Koinzidenz eines epiduralen Hämatoms und epiduralen Metastasengewbes bei thorakaler Epiduralanästhesie. Anaesthesist 2003;52:925–8.Google Scholar

  • [65]

    Lee BB. Neuraxial complications after spinal and epidural anaesthesia. Acta Anaesthesiol Scand 2003;47:371–3.Google Scholar

  • [66]

    Muir JJ, Church EJ, Weinmeister KP. Epidural hematoma associated with dextran infusion. South Med J 2003;96:811–4.Google Scholar

  • [67]

    Otsu I, Merrill D. Epidural hematoma after epidural anesthesia: a case report of non-surgical management. Acute Pain 2003;4:117–20.Google Scholar

  • [68]

    Rodi Z, Straus I, Denic K, Deletis V, Vodusek DB. Transient paraplegia revealed by intraoperative neurophysiological monitoring: was it caused by the epidural anesthetic or an epidural hematoma. Anesth Analg 2003;96:1785–8.Google Scholar

  • [69]

    Sidiropoulou T, Pompeo E, Bozzao A, Lunardi P, Dauri M. Epidural hematoma after thoracic epidural catheter removal in the absence of risk factors. Reg Anesth Pain Med 2003.Google Scholar

  • [70]

    Zink M, Rath M, Waltensdorfer A, Engler J, Rumpold-Seitinger G, Toller W, Reinhardt F. Unilateral presentation of a large epidural hematoma. Anesthesiology 2003;98:1032–3.Google Scholar

  • [71]

    Chan L, Bailin MT. Spinal epidural hematoma following central neuraxial blockade and subcutaneous enoxaparin: a case report. J Clin Anesth 2004;16:382–5.Google Scholar

  • [72]

    Cullen DJ, Bogdanov E, Htut N. Spinal epidural hematoma occurrence in the absence of known risk factors: a case series. J Clin Anesth 2004;16:376–81.Google Scholar

  • [73]

    Gottschalk A, Bischoff P, Lamszus K, Strandl T. Epidural hematoma after spinal anesthesia in a patient with undiagnosed epidural lymphoma. Anesth Analg 2004:1181–3.Google Scholar

  • [74]

    Litz RJ, Gottschlich B, Stehr SN. Spinal epidural hematoma after spinal anesthesia in a patient treated with clopidogrel and enoxaparin. Anesthesiology 2004;101:1467–70.Google Scholar

  • [75]

    Rosen DA, Hawkinberry II DW, Rosen KR, Gustafson RA, Hogg JP, Broadman LM. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 2004;98:966–9.Google Scholar

  • [76]

    Schwarz SKW, Wong CL, McDonald WN. Spontaneous recovery from a spinal epidural hematoma with atypical presentation in a nonagenarian. Can J Anesth 2004;51:557–61.Google Scholar

  • [77]

    Sharma S, Kapoor MC, Sharma VK, Dubey AK. Epidural hematoma complicating high thoracic epidural catheter placement intended for cardiac surgery. J Cardiovasc Anesth 2004;18:759–62.Google Scholar

  • [78]

    Özgen S, Baykan N, Dogan IV, Konya D, Necmettin P. Cauda equina syndrome after induction of spinal anesthesia. Neurosurg Focus 2004;16:24–7.Google Scholar

  • [79]

    Ain RJ, Vance MB. Epidural hematoma after epidural steroid injection in a patient withholding enoxaparin per guidelines. Anesthesiology 2005;102:701–3.Google Scholar

  • [80]

    Hyderally HA. Epidural hematoma unrelated to combined spinal–epidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement. Anesth Analg 2005;100:882–3.Google Scholar

  • [81]

    Miyazaki M, Takasita M, Matsumoto H, Sonoda H, Tsumura H, Toriso T. Spinal epidural hematoma after removal of an epidural catheter. J Spinal Disord Tech 2005;18:547–51.Google Scholar

  • [82]

    Robins K, Saravanan S, Watkins EJ. Ankylosing spondylitis and epidural haematoma. Anaesthesia 2005;60:617–32.Google Scholar

  • [83]

    Afzal A, Hawkins F, Rosenquist RW. Epidural hematoma in a patient receiving epidural analgesia and LMWH after total-knee arthroplasty. Reg Anesth Pain Med 2006;31:480.Google Scholar

  • [84]

    Agustin E, Aldecoa C, Rico-Feijoo J, Gómes-Herreras JI. Delayed sub-arachnoid hematoma after continuous epidural anesthesia in a patient without risk factors: good outcome after late laminectomy. Anesth Analg 2006;103:1599–600.Google Scholar

  • [85]

    Chan MY, Lindsay DA. Subdural spinal hematoma after epidural anesthesia in a patient with spinal canal stenosis. Anaesth Intensive Care 2006;34: 269–75.Google Scholar

  • [86]

    Dinsmore J, Nightingale J, Baker S. Delayed diagnosis of an epidural haematoma with a working epidural in situ. Anaesthesia 2006;61:912–3.Google Scholar

  • [87]

    SreeHarsha CK, Rajasekaran S, Dhanasekara R. Spontaneous complete recovery of paraplegia caused by epidural hematoma complicating epidural anesthesia: a case report and review of the literature. Spinal Cord 2006;44:514–7.Google Scholar

  • [88]

    Tam NLK, Pac-Soo C, Pretorius PM. Epidural haematoma after a combined spinal–epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br J Anaesth 2006;96:262–5.Google Scholar

  • [89]

    Boco T, Deutch H. Delayed symptomatic presentation of epidural hematoma after epidural catheter anesthesia: case report. Spine 2007;32:E649–51.Google Scholar

  • [90]

    Flisberg P, Friberg H. Epidural anaesthesia complications – early warning signs. Acta Anaesthesiol Scand 2007;51:264–5.Google Scholar

  • [91]

    Magalhaes E, Goveia CS, de Araujo Ladeira LC, de Queiroz LES. Hematoma after epidural anesthesia: conservative treatment. Case report. Rev Bras Anestesiol 2007;57:182–7.Google Scholar

  • [92]

    Park J-H, Shin K-M, Hong S-J, Kim I-S, Nam S-K. Subacute spinal subarachnoid hematoma after spinal anesthesia that causes mild neurologic deterioration. Anesthesiology 2007;107:846–8.Google Scholar

  • [93]

    Segabinazzi D, Brescianini BC, Schneider FG, Mendes FF. Conservative treatment of hematoma after spinal anesthesia: case report and literature review. Rev Bras Anestesiol 2007;57:188–94.Google Scholar

  • [94]

    Varitimidis SE, Paterakis K, Dailiana ZH, Hanres M, Georgopoulou S. Epidural hematoma secondary to removal of an epidural catheter after a total knee replacement. A case report. J Bone Joint Surg Am 2007;89:2048–50.Google Scholar

  • [95]

    Davignon KR, Maslow A, Chaudrey A, Ng T, Shore-Lesserson L, Rosenblatt MA. Epidural hematoma: when is it safe to heparinize after the removal of an epidural catheter? J Cardiothorac Vasc Anesth 2008;5:774–8.Google Scholar

  • [96]

    Hans GA, Senard M, Ledoux D, Grayet B, Scholtes F, Creemers E, Lamy ML. Cerebral subarachnoid blood migration consecutive to a lumbar haematoma after spinal anaesthesia. Acta Anaesthesiol Scand 2008;52:1021–3.Google Scholar

  • [97]

    Kaneda T, Urimoto G, Suzuki T. Spinal epidural hematoma following epidural catheter removal during antiplatelet therapy with cilostazol. J Anaesth 2008;22:290–3.Google Scholar

  • [98]

    Lam DH. Subarachnoid haematoma after spinal anaesthesia mimicking transient radicular irritation: a case report and review. Anaesthesia 2008;63:423–7.Google Scholar

  • [99]

    Nitz P, Laubenthal H, Haller S, Mumme A, Meiser A. Symptomatic epidural haematoma under therapeutic dose heparin: occurrence after removal of a peridural catheter. Anästhesist 2008;57:57–60.Google Scholar

  • [100]

    Pöpping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM. Effectiveness and safety of postoperative pain management: a survey of 18925 consecutive patients between 1998 and 2006. Br J Anaesth 2008;101:832–40.Google Scholar

  • [101]

    Singh DK, Chauhan M, Gupta V, Chopra S, Bagaria HR. Spinal subdural hematoma: a rare complication of spinal anesthesia: a case report. Turk Neurosurg 2008;18:324–6.Google Scholar

  • [102]

    Bindelglass DF, Rosenblum DS. Neuraxial hematoma and paralysis after enoxaparin administration 3 days after attempted spinal anesthesia for total knee arthroplasty. J Arthroplasty 2009. October 16 [Epub ahead of print].Google Scholar

  • [103]

    Eipe N, Restrepo-Garces CE, Aviv RI, Awad IT. Spinal epidural hematoma following epidural catheter removal in a paraplegic patient. J Clin Anesth 2009;21:525–8.Google Scholar

  • [104]

    Elwood D, Koo C. Intraspinal hematoma following neuraxial anesthesia and low-molecular-weight heparin in two patients: risks and benefits of anticoagulation. PM&R 2009;1:389–96.Google Scholar

  • [105]

    Fakouri B, Srinivas S, Magaji S, Kunsky A, Cacciola F. Spinal epidural hematoma after insertion of a thoracic epidural catheter in the absence of coagulation disorders – a call for raised awareness. Neurol India 2009;57:512–3.Google Scholar

  • [106]

    Kasodekar SV, Goldszmidt E, Davies SR. Atypical presentation of an epidural hematoma in a patient receiving aspirin and low molecular weight heparin. Was epidural analgesia the right choice? J Clin Anesth 2009;21:595–8.Google Scholar

  • [107]

    Moussallem CD, El-Yahchouchi CA, Charbel AC, Nohra G. Late spinal subdural haematoma after spinal anaesthesia for total hip replacement. J Bone Joint Surg 2009;91:1531–2.Google Scholar

  • [108]

    Rocchi R, Lombardi C, Marradi I, Di Paolo M, Cerase A. Intracranial and intraspinal hemorrhage following spinal anesthesia. Neurol Sci 2009;30:393–6.Google Scholar

  • [109]

    Ulivieri S, Olivieri G. Spinal epidural hematoma following epidural anesthesia. Case report. G Chir 2009;30:51–2.Google Scholar

  • [110]

    Xu R, Bydon M, Gokaslan ZL, Wolinsky J-P, Witham TF, Bydon A. Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines. J Neurosurg Spine 2009;11:358–64.Google Scholar

  • [111]

    Yoo HS, Park SW, Han JH, Chung JY, Yi JW, Kang JM, Lee BJ, Kim DO. Paraplegia caused by an epidural hematoma in a patient with unrecognized chronic idiopathic thrombocytopenic purpura following an epidural steroid injection. Spine 2009;34:E376–9.Google Scholar

  • [112]

    Zeynenoglu P, Gulsen S, Camkiran A, Ulu EMK, Aslim E, Pirat A. An epidural hematoma after epidural anesthesia for endovascular aortic aneurysm repair. J Cardiothorac Vasc Anesth 2009;23:580–2.Google Scholar

  • [113]

    Cerroni A, Carvalho JA, Tancredi A, Volpe AR, Floccari A. Acute bleeding after spinal anaesthesia due to puncture of unsuspected lumbar myxopependimoma. Eur J Anaesth 2010;27:1072–4.Google Scholar

  • [114]

    Guffey PJ, McKay R, McKay RE. Epidural hematoma nine days after removal of a labor epidural catheter. Anesth Analg 2010;111:992–5.Google Scholar

  • [115]

    Han IS, Chung EY, Hahn Y-J. Spinal epidural hematoma after epidural anesthesia in a patient receiving enoxaparin – a case report. Korean J Anesthesiol 2010;59:119–22.Google Scholar

  • [116]

    Koyama S, Tomimatsu T, Kanagawa T, Sawada K, Tsutsui T, Kimura T, Chang YS, Wasada K, Imai S, Murata Y. Spinal subarachnoid hematoma following spinal anesthesia in a patient with HELLP syndrome. Int J Obstet Anesth 2010;19:87–91.Google Scholar

  • [117]

    Li S-L, Wang D-X, Ma D. Epidural hematoma after neuraxial blockade: a retrospective report from China. Anesth Analg 2010;111:1322–4.Google Scholar

  • [118]

    Perrini P, Pieri F, Montemurro N, Tiezzi G, Parenti GF. Thoracic epidural haematoma after epidural anaesthesia. Neurol Sci 2010;31:87–8.Google Scholar

  • [119]

    Bang J, Kim JU, Lee YM, Joh J, An E-H, Lee L-Y, Kim JY, Choi I-C. Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient – a case report. Korean J Anesthesiol 2011;61:524–7.Google Scholar

  • [120]

    Chung J-H, Hwang J, Cha S-C, Jung T, Woo SC. Epidural hematoma occurred by massive bleeding intraoperatively in caesarean section after combined spinal epidural anesthesia – a case report. Korean J Anesthesiol 2011;61:336–40.Google Scholar

  • [121]

    Goswami D, Das J, Deuri A, Deka AK. Epidural haematoma: rare complication after spinal while intending epidural anaesthesia with long-term follow-up after conservative treatment. Indian J Anaesth 2011;55:71–3.Google Scholar

  • [122]

    Karakosta A, Kyrallidou A, Chapsa C, Pouliou A. Acute spinal anaesthesia treated conservatively: case report. Eur J Anaesth 2011;28:388–90.Google Scholar

  • [123]

    Seouw K, Drummond KJ. Subdural spinal haematoma after spinal anaesthesia in a patient taking aspirin. J Clin Neurosci 2011;18:1713–5.Google Scholar

  • [124]

    Shantanna H, Park J. Acute epidural haematoma following epidural steroid injection in a patient with spinal stenosis. Anaesthesia 2011;66:837–9.Google Scholar

  • [125]

    Souza RL, Andrade LOF, Silva JB, Silva LAC. Neuraxial hematoma after epidural anesthesia. Is it possible to prevent or detect it? Report of two cases. Rev Bras Anesthesiol 2011;61:218–24.Google Scholar

  • [126]

    Wajima Z, Aida S. Does hyperbaric oxygen have positive effect on neurological recovery in spinal–epidural haematoma? A case report. Br J Anaesth 2011;106:785–91.Google Scholar

  • [127]

    Barbara DW, Smith BC, Arendt KW. Images in anaesthesiology: spinal subdural hematoma after labor epidural placement. Anesthesiology 2012;117:178.Google Scholar

  • [128]

    Chung JY, Han JH, Kang JM, Lee BJ. Paraplegia after epidural steroid injection. Anaesth Intensive Care 2012;40:1074–6.Google Scholar

  • [129]

    Luo F, Cai XJ, Li ZY. Subacute spinal subarachnoid hematoma following combined spinal–epidural anesthesia treated conservatively: a case report. J Clin Anesth 2012;24:519–20.Google Scholar

  • [130]

    Madhugiri VS, Singh M, Sasidharan GM, Kumar VRR. Remote spinal epidural haematoma after spinal anaesthesia presenting with a ‘spinal lucid interval’. BMJ Case Rep 2012, http://dx.doi.org/10.1136/bcr-2012-007258. Published October 29.

  • [131]

    Takawira N, Han RJ, Nguyen TQ, Gaines JD, Han TH. Spinal cord stimulator and epidural haematoma. BJA 2012;109:649–50.Google Scholar

  • [132]

    Walters MA, Van de Velde M, Wilms G. Acute intrathecal haematoma following neuraxial anaesthesia: diagnostic delay after apparently normal radiological imaging. Int J Obstet Anesth 2012;21:181–5.Google Scholar

  • [133]

    Volk T, Wolf A, Van Aken H, Bürkle H, Wielbalck A, Steinfeldt T. Incidence of spinal haematoma after epidural puncture: analysis from the German network for safety in regional anaesthesia. Eur J Anaesthesiol 2012;29:170–6.Google Scholar

  • [134]

    Yao W, Wang X, Xu H, Luo A, Zhang C. Unilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after caesarean section under epidural anesthesia. J Anesth 2012;26:949–50.Google Scholar

  • [135]

    Caputo AM, Gottfried ON, Nimjee SM, Brown CR, Michael KW, Richardson WJ. Spinal epidural hematoma following epidural steroid injection in a patient treated with dabigatran. JBJS Case Connect 2013;3:e64.Google Scholar

  • [136]

    Jeon SB, Ham T-I, Kang M-S, Shim H-Y, Park SL. Spinal subarachnoid hematoma after spinal anesthesia. Korean J Anesthesiol 2013;64:388–9.Google Scholar

  • [137]

    Ladha A, Alam A, Idestrup C, Sawyer J, Choi S. Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency. Anaesthesia 2013;68:856–60.Google Scholar

  • [138]

    Buvanedran A, Young AC. Spinal epidural hematoma after spinal cord stimulator trial lead placement in a patient taking aspirin. Reg Anesth Pain Med 2014;39:70–2.Google Scholar

  • [139]

    Chang Chien GC, McCormick Z, Araujo M, Candido KD. The potential contributing effect of ketorolac and fluoxetine to a spinal hematoma following interlaminar epidural steroid injection: a case report and narrative review. Pain Phys 2014;17:E385–95.Google Scholar

  • [140]

    Doctor JR, Ranganathan P, Divatia JV. Paraplegia following epidural analgesia: a potentially avoidable cause? Saudi J Anaesth 2014;8:284–6.Google Scholar

  • [141]

    Feltracco P, Galligioni H, Barbieri S, Ori C. Transient paraplegia after epidural catheter removal during low molecular heparin prophylaxis. Eur J Anaesthesiol 2014;31:172–80.Google Scholar

  • [142]

    Giberson CE, Barbosa J, Brooks ES, McGlothlen GL, Grigsby EJ, Kohut JJ, Wolbers LL, Poree LR. Epidural hematomas after removal of percutaneous spinal cord stimulator trial leads. Two case reports. Reg Anesth Pain Med 2014;39: 73–7.Google Scholar

  • [143]

    Iwashita K, Shigematsu K, Higa K, Nitahar K. Spontaneous recovery of paraplegia caused by spinal epidural hematoma after removal of epidural catheter. Case Rep Anesthesiol 2014;2014:291728.Google Scholar

  • [144]

    Kobayashi Y, Nakada J, Kuroda H, Sakakura N, Usami N, Sakao Y. Spinal epidural hematoma during anticoagulant therapy for pulmonary embolism: postoperative complications in a patient with lung cancer. Ann Thorac Cardiovasc Surg 2014;(Suppl.):493–6.Google Scholar

  • [145]

    Makris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord 2014;52:S14–6.Google Scholar

  • [146]

    Radcliff KE, Ong A, Parvizi J, Post Z, Orozco F. Rivaroxaban-induced epidural hematoma and cauda equina syndrome after total knee arthroplasty: a case report. Orthop Surg 2014;6:669–71.Google Scholar

  • [147]

    Schroll J, Giurguis M, D’Mello A, Mroz T, Lin J, Farag E. Epidural hematoma with atypical presentation. A&A Case Rep 2014;2:75–7.Google Scholar

  • [148]

    Wang J, Lau ME, Gulur P. Delayed spinal epidural hematoma after epidural catheter removal with reinitiation of warfarin. J Cardiovasc Anesth 2014;28:1566–9.Google Scholar

  • [149]

    Avecillas-Chasin JM, Matias-Guiu JA, Gomez G, Saceda-Guiterrez J. A case of acute spinal intradural hematoma due to spinal anesthesia. J Acute Dis 2015;4:341–3.Google Scholar

  • [150]

    Goyal LD, Kaur H, Singh A. Cauda equine syndrome after repeated spinal attempts: a case report and review of the literature. Saudi J Anaesth 2015;9:214–6.Google Scholar

  • [151]

    Lee JK, Chae KW, Ju C, Kim BW. Acute cervical subdural hematoma with quadriparesis after cervical transforaminal epidural block. J Korean Neurosurg Soc 2015;58:483–6.Google Scholar

  • [152]

    Madhisetti KR, Mathew M, Pillai SS. Spinal epidural haematoma following rivaroxaban administration after total knee replacement. Indian J Anaesth 2015;59:519–21.Google Scholar

  • [153]

    Singhal N, Sethi P, Agarwal S. Spinal subdural hematoma with cauda equina syndrome: a complication of spinal epidural anesthesia. J Anesthesiol Clin Pharmacol 2015;31:244–5.Google Scholar

  • [154]

    Staikou C, Stamelos M, Boutas I, Koutoulidis V. Undiagnosed vertebral hemangioma causing a lumbar compression fracture and epidural hematoma in a parturient undergoing vaginal delivery under epidural analgesia: a case report. Can J Anesth 2015;62:901–6.Google Scholar

  • [155]

    Breschan C, Krumpholz R, Jost R, Likar R. Intraspinal haematoma following lumbar epidural anaesthesia in a neonate. Paediatr Anaesth 2001;11: 105–8.Google Scholar

  • [156]

    Diyora B, Sharma A, Mamidanna R, Kamat L. Chronic cervicothoracic spinal subdural hematoma. Neurol Med Chir (Tokyo) 2009;49:310–2.Google Scholar

  • [157]

    Walker C, Ingram I, Edwrads D, Wood P. Use of thromboelastometry in the assessment of coagulation before epidural insertion after massive transfusion. Anaesthesia 2011;66:52–5.Google Scholar

  • [158]

    van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010;148:15–25.Google Scholar

  • [159]

    Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, Rauck R, Huntoon MA. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications guidelines. From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, The American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015;40:182–212.Google Scholar

  • [160]

    Sprung J, Bourke DL, Grass J, Hammel J, Mascha E, Thomas P, Tubin I. Predicting the difficult neuraxial block: a prospective study. Anesth Analg 1999;89:384–9.Google Scholar

  • [161]

    Horlocker TT, McGregor D, Matsushige DK, Schroeder DR, Besse JA. A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Anesth Analg 1997;84:578–84.Google Scholar

  • [162]

    Samama CM, Albaladejo P, Benhamou D, Bertin-Maghit M, Bruder N, Doublet JD, Laversin S, Leclerc S, Marret E, Mismetti P, Samain E, Steib A. Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. Eur J Anaesthesiol 2006;23:95–116.Google Scholar

  • [163]

    Pitkänen MT, Aromaa U, Cozanitis DA, Förster JG. Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiol Scand 2013;57:553–64.Google Scholar

  • [164]

    The Swedish National Board of Health and Welfare. Available from:

  • [165]

    Horlocker TT, Wedel DJ, Schroeder DR, Rose SH, Elliott BA, McGregor DG, Wong GY. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995;80:303–9.Google Scholar

  • [166]

    Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth 2011;107:i96–106.Google Scholar

  • [167]

    Petraglia FW, Farber SH, Gramer R, Verla T, Wang F, Thomas S, Parente B, Lad SP. The incidence of spinal cord injury in implantation of percutaneous and paddle electrodes for spinal cord stimulation. Neuromodulation 2016;19:85–90.Google Scholar

  • [168]

    Moufarrij NA. Epidural hematomas after the implantation of thoracic paddle spinal cord stimulators. J Neurosurg 2016, http://dx.doi.org/10.3171/2015.8.JNS15396. Published online January 8, 2016.

  • [169]

    CDC/NCHS National Hospital Discharge Survey. Available from: www.cdc.gov; 2010 [latest accessed 27.10.16].

  • [170]

    London School of Hygiene & Topical Medicine. Cited in The Daily Telegraph. Accessed at https://en.wikipedia.org/wiki/Human_body_weight; 21 June 2012.

  • [171]

    DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National health statistics reports; no. 5. Hyattsville, MD: National Center for Health Statistics; 2008. Available from: www.cdc.gov [latest accessed 27.10.16].

  • [172]

    Aglietti P, Baldini A, Vena LM, Abbate R, Fedi S, Falciani M. Effect of tourniquet use on activation of coagulation in total knee replacement. Clin Orthop Res 2000;371:169–77.Google Scholar

  • [173]

    Smith TO, Hing CB. Is a tourniquet beneficial in total knee replacement surgery? A meta-analysis and systematic review. Knee 2010;17:141–7.Google Scholar

  • [174]

    Alcelik I, Pollock RD, Sukeik M, Bettany-Saltikov J, Armstrong PM, Fismer P. A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2012;27:331–40.Google Scholar

  • [175]

    Heller AR, Litz RJ. Why do orthopedic patients have a higher incidence of serious complications after central neuraxial blockade? Anesthesiology 2005;102:1286.Google Scholar

  • [176]

    The Swedish Knee Arthroplasty Register. Accessed at http://stat.myknee.se.

  • [177]

    Cook TM, Counsell D, Wildsmith JAW. Major complications of central neuraxial blocks: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009;102:179–90.Google Scholar

  • [178]

    Campbell NR, Hull RD, Brant R, Hogan DB, Pineo GF, Raskob GE. Different effects of heparin in males and females. Clin Invest Med 1998;21:71–8.Google Scholar

  • [179]

    Oldgren J, Johnston N, Siegbahn A. Xa inhibition and coagulation activity – the influence of prolonged dalteparin treatment and gender in patients with acute coronary syndrome and healthy individuals. Am Heart J 2008;155:493–8.Google Scholar

  • [180]

    Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1–49.Google Scholar

  • [181]

    Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter MSaville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493.Google Scholar

  • [182]

    Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology 2012;117:72–92.Google Scholar

  • [183]

    Pöpping DM, Elia N, Van Aken HK, Marret E, Schug SA, Kranke P, Wenk M, Tramèr MR. Impact of epidural analgesia on mortality and morbidity after surgery. Systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014;259:1056–67.Google Scholar

  • [184]

    Memtsoudis SG, Sun X, Chiu Y-L, Nurok M, Stundner O, Pastores SM, Mazumdar M. Utilization of critical care services among patients undergoing total hip and knee arthroplasty. Epidemiology and risk factors. Anesthesiology 2012;117:107–16.Google Scholar

  • [185]

    Breivik H, Norum H, Fenger-Eriksen C, Alahuhta S, Vigfússon G, Thomas O, Lagerkranser M. Reducing risk of spinal cord injury in patients who benefit from neuraxial blocks but have disturbed haemostasis. Acta Anaesthesiol Scand 2017 [submitted].Google Scholar

About the article

Vantvägen 32, 133 44 Saltsjäbaden, Sweden.

Published Online: 2017-04-01

Published in Print: 2017-04-01

Funding: No funding or financial support has been received.

Ethical issues: None.

Conflict of interest: No conflict of interests is declared.

Citation Information: Scandinavian Journal of Pain, Volume 15, Issue 1, Pages 118–129, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2016.11.008.

Export Citation

© 2017 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

Anne Godier and Sébastien Bloc
Anaesthesia Critical Care & Pain Medicine, 2019, Volume 38, Number 5, Page 457
Harald Breivik, Hilde Norum, Christian Fenger-Eriksen, Seppo Alahuhta, Gísli Vigfússon, Owain Thomas, and Michael Lagerkranser
Scandinavian Journal of Pain, 2018, Volume 18, Number 2, Page 129
P. Sierra, A. Gómez-Luque, J.V. Llau, R. Ferrandis, C. Cassinello, F. Hidalgo, Juan I. Arcelus, Pedro Díaz, Ana Díez, Lourdes Durán, Bartolomé Fernández, Enrique Gil-Garay, Ana González, José Luis Jover, José Mateo, María Navarro, Artur Oliver, Alejandro Ponz, Inmaculada Renart, Ángela M. Soriano, David Vivas, and Gabriel J. Yanes
Revista Española de Anestesiología y Reanimación (English Edition), 2019, Volume 66, Number 1, Page 18

Comments (0)

Please log in or register to comment.
Log in