title: Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.
abstract: We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 10(9)/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1-20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention.
  
  
  CONCLUSIONS
  Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA. horlocker.terese@mayo.edu
authors.forename: Terese T
authors.initials: TT
authors.lastname: Horlocker
authors.forename: Zahid H
authors.initials: ZH
authors.lastname: Bajwa
authors.forename: Zubaira
authors.initials: Z
authors.lastname: Ashraf
authors.forename: Sajid
authors.initials: S
authors.lastname: Khan
authors.forename: Jack L
authors.initials: JL
authors.lastname: Wilson
authors.forename: Naveed
authors.initials: N
authors.lastname: Sami
authors.forename: Christine
authors.initials: C
authors.lastname: Peeters-Asdourian
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Powers
authors.forename: Darrell R
authors.initials: DR
authors.lastname: Schroeder
authors.forename: Paul A
authors.initials: PA
authors.lastname: Decker
authors.forename: Carol A
authors.initials: CA
authors.lastname: Warfield
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D001416:Back Pain / Q000188:drug therapy*; D004824:Epidural Space; D005260:Female; D006408:Hematoma, Subdural / Q000139:chemically induced*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D000305:Adrenal Cortex Hormones; D000894:Anti-Inflammatory Agents, Non-Steroidal; D010975:Platelet Aggregation Inhibitors