title: Acute Epidural Hematoma Formation in Cervical Spine After Interlaminar Epidural Steroid Injection Despite Discontinuation of Clopidogrel.
abstract: BACKGROUND
  Perioperative management of patients on anticoagulant therapy prior to interventional pain procedures creates a challenge when balancing the risk of bleeding against thromboembolic events.
  
  
  METHODS
  We report a case of epidural hematoma formation in the cervical spine following interlaminar epidural steroid injection in an elderly woman with chronic neck and arm pain, who was on clopidogrel therapy.
  
  
  CONCLUSIONS
  This is the first reported case of hematoma formation immediately following an epidural steroid injection possibly associated with clopidogrel, even though established guidelines on the timing of the discontinuation of clopidogrel prior to the procedure were exceeded. Severe pain appears to be the first symptom of hematoma formation, and therefore immediate diagnostic workup and evacuation of hematoma are essential in preventing neurological damage. It may be advisable to carry out a test specific for clopidogrel such as the P2Y12 to ensure that there is no residual action on platelet aggregation function, particularly in patients who may be slow metabolizers of clopidogrel. Caution is advised prior to administering analgesics with antiplatelet effects such as ketorolac.
authors.affiliation: From the *Millennium Pain Center, Bloomington; †Department of Surgery, University of Illinois, College of Medicine, Champaign; ‡Department of Biological Sciences, Illinois State University, Normal; and §Illinois Wesleyan University, Bloomington, IL; ∥Department of Neurology, University of Utah, Salt Lake City, UT; and ¶Division of Vascular and Interventional Radiology, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Ramsin M
authors.initials: RM
authors.lastname: Benyamin
authors.forename: Ricardo
authors.initials: R
authors.lastname: Vallejo
authors.forename: Victor
authors.initials: V
authors.lastname: Wang
authors.forename: Nitesh
authors.initials: N
authors.lastname: Kumar
authors.forename: David L
authors.initials: DL
authors.lastname: Cedeño
authors.forename: Anobel
authors.initials: A
authors.lastname: Tamrazi
mesh_terms: D000208:Acute Disease; D000369:Aged, 80 and over; D001623:Betamethasone / Q000008:administration & dosage*; D002574:Cervical Vertebrae; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy*; D000077144:Clopidogrel; D019299:Decompression, Surgical; D004334:Drug Administration Schedule; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage*; D046748:Hematoma, Epidural, Spinal / Q000139:chemically induced* / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects; D007796:Laminectomy; D008279:Magnetic Resonance Imaging; D019547:Neck Pain / Q000175:diagnosis / Q000188:drug therapy*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D012307:Risk Factors; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D005938:Glucocorticoids; D010975:Platelet Aggregation Inhibitors; D001623:Betamethasone; D000077144:Clopidogrel; D013988:Ticlopidine