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Letter to the Editor

Int J Pain 2023; 14(1): 35-36

Published online June 30, 2023 https://doi.org/10.56718/ijp.23-008

Copyright © The Korean Association for the Study of Pain.

Reply to the Comments on “Intradural Extramedullary Hematoma after Cervical Epidural Injection: A Case Report” by Oh et al.

Ji Won Choi

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea

Correspondence to:Ji Won Choi, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea. Tel: +82-2-3410-6589, Fax: +82-2-3410-6589, E-mail: jiwon0715.choi@samsung.com

Received: May 27, 2023; Accepted: May 27, 2023

We would like to express our gratitude for your valuable comments on our report, and we agree with some of your opinions. The authors extensively discussed the mechanism of intradural extramedullary (IDEM) hematoma in our case. As you correctly pointed out, it is theoretically possible for a hematoma caused by cervical interlaminar epidural steroid injection (CESI) to develop in the posterior epidural space.

Some studies have reported that the paramedian approach of CESI may inadvertently enter the intradural space, which is highly undesirable [1,2]. It has also been recently recognized that the paramedian approach allows for direct access and solution transfer over the ventral epidural space and the dorsal root ganglion [3-5]. In fact, one study showed that the paramedian approach resulted in a significantly higher proportion of ventral epidural spread compared to the midline approach [6].

However, this alone does not fully explain the occurrence of IDEM hematoma, particularly at the anterior aspect of the spinal cord in our case. The neurosurgeon who performed the operation observed a well-developed network of venous structures, resembling capillaries, surrounding the hematoma. Furthermore, it is known that even minimal injuries can lead to the development of intradural hematoma through a sequential series of pachymeningeal pathologies, especially in the elderly. Trauma-induced loss of integrity in the pachymeninges and the expression of anticoagulants have been suggested as possible mechanisms [7,8].

In this case report, we believe that several factors mentioned above may have contributed to the occurrence of IDEM hematoma anterior to the spinal cord. However, further studies or case series are necessary to confirm the exact mechanism.

No potential conflict of interest relevant to this article was reported.

  1. Hogan QH: Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease. Reg Anesth 1996; 21: 395-406.
  2. Yoon JY, Kwon JW, Yoon YC, Lee J: Cervical interlaminar epidural steroid injection for unilateral cervical radiculopathy: comparison of midline and paramedian approaches for efficacy. Korean J Radiol 2015; 16: 604-12.
    Pubmed KoreaMed CrossRef
  3. Makkar JK, Gourav KKP, Jain K, Singh PM, Dhatt SS, Sachdeva N, et al: Transforaminal versus lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of unilateral radicular lumbar pain: a randomized double-blind trial. Pain Physician 2019; 22: 561-73.
    CrossRef
  4. Hashemi M, Mofrad MK, Mohajerani SA, Kazemi SM, Radpey B, Zali A: Anatomical flow pattern of contrast in lumbar epidural space: a human study with a midline vs. parasagittal interlaminar approach under fluoroscopy. Pain Physician 2015; 18: 317-24.
    CrossRef
  5. Hashemi M, Dadkhah P, Taheri M, Dehghan K, Valizadeh R: Cervical epidural steroid injection: parasagittal versus midline approach in patients with unilateral cervical radicular pain; a randomized clinical trial. Bull Emerg Trauma 2019; 7: 137-43.
    Pubmed KoreaMed CrossRef
  6. Murakami H, Hirose Y, Sagoh M, Shimizu K, Kojima M, Gotoh K, et al: Why do chronic subdural hematomas continue to grow slowly and not coagulate? Role of thrombomodulin in the mechanism. J Neurosurg 2002; 96: 877??4.
    Pubmed CrossRef
  7. Lee JH, Lee DC, Lee JH: Does paramedian approach preferentially secure optimal drug delivery onto ventral epidural space and subsequent superior clinical efficacy over a dorsal midline approach during cervical interlaminar epidural injection? Pain Physician 2021; 24: E839-47.
    CrossRef
  8. Atkinson JL, Lane JI, Aksamit AJ: MRI depiction of chronic intradural (subdural) hematoma in evolution. J Magn Reson Imaging 2003; 17: 484-6.
    Pubmed CrossRef

Article

Letter to the Editor

Int J Pain 2023; 14(1): 35-36

Published online June 30, 2023 https://doi.org/10.56718/ijp.23-008

Copyright © The Korean Association for the Study of Pain.

Reply to the Comments on “Intradural Extramedullary Hematoma after Cervical Epidural Injection: A Case Report” by Oh et al.

Ji Won Choi

Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea

Correspondence to:Ji Won Choi, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea. Tel: +82-2-3410-6589, Fax: +82-2-3410-6589, E-mail: jiwon0715.choi@samsung.com

Received: May 27, 2023; Accepted: May 27, 2023

Body

We would like to express our gratitude for your valuable comments on our report, and we agree with some of your opinions. The authors extensively discussed the mechanism of intradural extramedullary (IDEM) hematoma in our case. As you correctly pointed out, it is theoretically possible for a hematoma caused by cervical interlaminar epidural steroid injection (CESI) to develop in the posterior epidural space.

Some studies have reported that the paramedian approach of CESI may inadvertently enter the intradural space, which is highly undesirable [1,2]. It has also been recently recognized that the paramedian approach allows for direct access and solution transfer over the ventral epidural space and the dorsal root ganglion [3-5]. In fact, one study showed that the paramedian approach resulted in a significantly higher proportion of ventral epidural spread compared to the midline approach [6].

However, this alone does not fully explain the occurrence of IDEM hematoma, particularly at the anterior aspect of the spinal cord in our case. The neurosurgeon who performed the operation observed a well-developed network of venous structures, resembling capillaries, surrounding the hematoma. Furthermore, it is known that even minimal injuries can lead to the development of intradural hematoma through a sequential series of pachymeningeal pathologies, especially in the elderly. Trauma-induced loss of integrity in the pachymeninges and the expression of anticoagulants have been suggested as possible mechanisms [7,8].

In this case report, we believe that several factors mentioned above may have contributed to the occurrence of IDEM hematoma anterior to the spinal cord. However, further studies or case series are necessary to confirm the exact mechanism.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Hogan QH: Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease. Reg Anesth 1996; 21: 395-406.
  2. Yoon JY, Kwon JW, Yoon YC, Lee J: Cervical interlaminar epidural steroid injection for unilateral cervical radiculopathy: comparison of midline and paramedian approaches for efficacy. Korean J Radiol 2015; 16: 604-12.
    Pubmed KoreaMed CrossRef
  3. Makkar JK, Gourav KKP, Jain K, Singh PM, Dhatt SS, Sachdeva N, et al: Transforaminal versus lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of unilateral radicular lumbar pain: a randomized double-blind trial. Pain Physician 2019; 22: 561-73.
    CrossRef
  4. Hashemi M, Mofrad MK, Mohajerani SA, Kazemi SM, Radpey B, Zali A: Anatomical flow pattern of contrast in lumbar epidural space: a human study with a midline vs. parasagittal interlaminar approach under fluoroscopy. Pain Physician 2015; 18: 317-24.
    CrossRef
  5. Hashemi M, Dadkhah P, Taheri M, Dehghan K, Valizadeh R: Cervical epidural steroid injection: parasagittal versus midline approach in patients with unilateral cervical radicular pain; a randomized clinical trial. Bull Emerg Trauma 2019; 7: 137-43.
    Pubmed KoreaMed CrossRef
  6. Murakami H, Hirose Y, Sagoh M, Shimizu K, Kojima M, Gotoh K, et al: Why do chronic subdural hematomas continue to grow slowly and not coagulate? Role of thrombomodulin in the mechanism. J Neurosurg 2002; 96: 877??4.
    Pubmed CrossRef
  7. Lee JH, Lee DC, Lee JH: Does paramedian approach preferentially secure optimal drug delivery onto ventral epidural space and subsequent superior clinical efficacy over a dorsal midline approach during cervical interlaminar epidural injection? Pain Physician 2021; 24: E839-47.
    CrossRef
  8. Atkinson JL, Lane JI, Aksamit AJ: MRI depiction of chronic intradural (subdural) hematoma in evolution. J Magn Reson Imaging 2003; 17: 484-6.
    Pubmed CrossRef
The Korean Association for the Study of Pain

Vol.14 No.2
December 2023

pISSN 2233-4793
eISSN 2233-4807

Frequency: Semi-Annual

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