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Reducing risk of spinal haematoma from spinal and epidural pain procedures.
Scand J Pain. 2018 04 25; 18(2):129-150.SJ

Abstract

BACKGROUND AND AIMS

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.

METHODS

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.

RESULTS AND RECOMMENDATIONS

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.

CONCLUSIONS

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.

IMPLICATIONS

There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts' experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.

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Publisher Full Text (DOI)

Authors+Show Affiliations

Breivik H
Oslo University Hospital, Division of Emergencies and Critical Care, Department of Pain Management and Research, PB 4956 Nydalen, 0424 Oslo, Norway, Phone: +47 23073691, Fax: +47 23073690. University of Oslo, Faculty of Medicine, Oslo, Norway. Oslo University Hospital, Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo, Norway.
Norum H
University of Oslo, Faculty of Medicine, Oslo, Norway. Oslo University Hospital, Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo, Norway.
Fenger-Eriksen C
Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.
Alahuhta S
Department of Anaesthesiology, MRC Oulu, University of Oulu, and Oulu University Hospital, Oulu, Finland.
Vigfússon G
Department of Anaesthesia and Intensive Care, University Hospital Landspitalinn, Reykjavik, Iceland.
Thomas O
Institute of Clinical Sciences, University of Lund, and Department of Paediatric Anaesthesiology and Intensive Care, SUS Lund University Hospital, Lund, Sweden.
Lagerkranser M
Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.

MeSH

Anesthesia, EpiduralAnesthesia, SpinalHematomaHumansPostoperative ComplicationsRiskSpinal Cord Diseases

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

29794308

Citation

Breivik, Harald, et al. "Reducing Risk of Spinal Haematoma From Spinal and Epidural Pain Procedures." Scandinavian Journal of Pain, vol. 18, no. 2, 2018, pp. 129-150.
Breivik H, Norum H, Fenger-Eriksen C, et al. Reducing risk of spinal haematoma from spinal and epidural pain procedures. Scand J Pain. 2018;18(2):129-150.
Breivik, H., Norum, H., Fenger-Eriksen, C., Alahuhta, S., Vigfússon, G., Thomas, O., & Lagerkranser, M. (2018). Reducing risk of spinal haematoma from spinal and epidural pain procedures. Scandinavian Journal of Pain, 18(2), 129-150. https://doi.org/10.1515/sjpain-2018-0041
Breivik H, et al. Reducing Risk of Spinal Haematoma From Spinal and Epidural Pain Procedures. Scand J Pain. 2018 04 25;18(2):129-150. PubMed PMID: 29794308.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Reducing risk of spinal haematoma from spinal and epidural pain procedures. AU - Breivik,Harald, AU - Norum,Hilde, AU - Fenger-Eriksen,Christian, AU - Alahuhta,Seppo, AU - Vigfússon,Gísli, AU - Thomas,Owain, AU - Lagerkranser,Michael, PY - 2018/02/22/received PY - 2018/03/06/accepted PY - 2018/5/26/entrez PY - 2018/5/26/pubmed PY - 2019/4/16/medline KW - anticoagulants KW - epidural analgesia KW - platelet inhibitors KW - postoperative complications KW - practise advisory KW - spinal analgesia KW - spinal haematoma SP - 129 EP - 150 JF - Scandinavian journal of pain JO - Scand J Pain VL - 18 IS - 2 N2 - BACKGROUND AND AIMS: 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. METHODS: 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. RESULTS AND RECOMMENDATIONS: 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. CONCLUSIONS: 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. IMPLICATIONS: There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts' experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications. SN - 1877-8879 UR - https://www.unboundmedicine.com/medline/citation/29794308/Reducing_risk_of_spinal_haematoma_from_spinal_and_epidural_pain_procedures_ DB - PRIME DP - Unbound Medicine ER -