Vascular surgery patients at highest risk of spinal haematoma and epidural abscess
ESRA Academy. Wu C. Mar 7, 2017; 170355
Christopher Wu
Christopher Wu
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The development of epidural haematoma or epidural abscess is fortunately an uncommon and rare event. However, it is precisely because of the low frequency of such events that makes them difficult to study. Realistically, the only way to study the development of epidural haematoma or epidural abscess is through the use of large databases which is what Rosero and Joshi have done in this study. The authors used the National Inpatient Sample (NIS), which is a set of longitudinal hospital inpatient databases from the Agency of Healthcare Research and Quality (AHRQ) and the largest publicly available all-payer inpatient health care database in the USA, yielding more than 35 million hospitalisations nationally. The authors’ findings overall confirm prior research in this area; namely, that the incidence of epidural/spinal haematoma is lower in the obstetric than the non-obstetric population (0.6 per 100,000 versus 18.5 per 100,000 epidural catheterisations, respectively). The rates of epidural/spinal haematoma are within the range of previous studies.
The authors also noted a lower epidural abscess in the obstetric compared to the non-obstetric population (approximately 0 per 100,000 versus 7.2 per 100,000 epidural catheterisations, respectively). Prior research for epidural abscesses provides a wider range for the incidence of epidural abscess development, and comparison of the rates shown in this study with prior data is difficult; however, it is still important to note that previous studies also generally show a lower rate of epidural abscess in obstetric compared to non-obstetric patients. Finally, the authors noted that patients undergoing vascular surgery are at the highest risk of spinal haematoma and epidural abscess.
As with many database analysis, there are some limitations with this type of analysis. As noted by the authors, there may be under-coding of the epidural procedures and miscoding of epidural complications. Also, databases of this type generally lack the granularity needed to elucidate specific factors that may contribute to the development of epidural haematoma or epidural abscess. For instance in this case, the authors were unable to assess the presence of technique-specific risk factors, including level of catheter insertion, number of attempts, number of days the catheter was in place, and most importantly the use of anticoagulants, which may have contributed to the development of epidural haematoma or epidural abscess. Despite these limitations, this manuscript does add another piece of important information to our knowledge on this topic.


This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States.


The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately.


A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home.


This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.

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