Iatrogenic Spinal Epidural Hematoma Associated with Intracranial Hypotension

Epidural steroid injections (ESIs) are one of the few modalities currently in use for treating chronic spinal pain. There are two approaches: interlaminar ESIs and transforaminal ESIs. Complications arising from either approach are rare, but one such complication is cerebrospinal fluid (CSF) leak leading to intracranial hypotension. Even rarer is the development of iatrogenic spinal epidural hematoma in the context of the injections. Interestingly, an association with intracranial hypotension and spinal epidural hematoma has yet to be established. Even the characteristics of an iatrogenic spinal epidural hematoma are not well defined as there are different theories of how this develops and whether we are dealing with arterial or venous blood. Our case is unique as it appears our patient had developed not one, but both clinical symptoms supportive of intracranial hypotension from a CSF leak induced iatrogenically from a cervical epidural injection and imaging demonstrated thoracic-level spinal epidural hematoma. It is unclear whether the injection directly led to the spinal leak causing the intracranial hypotension, which then brought on the formation of the hematoma or if the injection led to both intracranial hypotension and hematoma formation independent of each other. From a clinical practice standpoint, given our case suggests the hematoma was concomitantly associated with intracranial hypotension, and the possibility exists that the hematoma may have formed in the context of the intracranial hypotension, then targeted blood patches may need to be done with greater urgency to preventing hematoma formation. Further studies are needed involving clotting factors comparing arterial and venous blood. It is also puzzling why the epidural blood from the hematoma did not clot the leak. This concomitancy deserves further attention and may lead to changes in how we manage cervical epidural injection patients who are found to have CSF leak and a spinal epidural hematoma.