BoardsBridgeEpidural Hematoma After Neuraxial Anesthesia
Bleeding into the epidural space compressing the cord — anticoagulation timing, red-flag neurology, and emergent decompression
Bleeding into the epidural space (usually from the internal vertebral venous plexus) after a neuraxial block or catheter removal, compressing the cord — a neurosurgical emergency the moment new neurologic symptoms appear.
If you forget
Headline: ANY new back pain + lower-extremity weakness or bladder/bowel change after a neuraxial block or catheter removal = STOP and assume epidural hematoma until proven otherwise.
Board trap
Key numbers
- Incidence ~1 in 150,000 epidurals; ~1 in 220,000 spinals (large population estimates)
- Symptom onset typically within 24-48 h of block or catheter removal; most within 24 h
- Surgical decompression ideally within ~8 h of symptom onset for neurologic recovery
- ASRA: hold therapeutic-dose LMWH (e.g., enoxaparin 1 mg/kg q12h) for ~24 h pre-neuraxial; remove indwelling catheter BEFORE the next scheduled dose
- ASRA: hold DOACs (apixaban/rivaroxaban) ~72 h pre-neuraxial with normal renal function; restart ≥24 h post-pull in high-bleed-risk patients
- Warfarin: neuraxial requires INR ≤1.5; remove indwelling catheter with INR ≤1.5
- Antiplatelet holds: clopidogrel/ticagrelor ~5-7 d; prasugrel ~7-10 d; aspirin alone is NOT a contraindication
Uri Rozen, MD — Licensed Physician, Israel
Source guidelines: ASRA Antithrombotic Regional Anesthesia 2025 · ASA Obstetric Anesthesia 2016
Re-review cadence: 12 months from reviewed date.
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Card ID: epidural-hematoma · Path: aba.regional.neuraxial-spinal-epidural.epidural-hematoma