Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines

J Neurosurg Spine. 2009 Sep;11(3):358-64. doi: 10.3171/2009.3.SPINE0916.


Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Anticoagulants / administration & dosage*
  • Female
  • Glucocorticoids / administration & dosage*
  • Guideline Adherence
  • Hematoma, Epidural, Spinal / diagnosis
  • Hematoma, Epidural, Spinal / etiology*
  • Hematoma, Epidural, Spinal / therapy
  • Humans
  • Injections, Epidural / adverse effects*
  • Low Back Pain / drug therapy
  • Low Back Pain / etiology
  • Lumbar Vertebrae
  • Practice Guidelines as Topic
  • Spinal Stenosis / complications
  • Spinal Stenosis / pathology


  • Anticoagulants
  • Glucocorticoids