Complications, Safety, and Risk Management
Core concepts
Know the complication profile of each intervention: bleeding and hematoma, infection, nerve injury, vascular injection, pneumothorax, dural puncture and post-dural puncture headache, local anesthetic systemic toxicity, and steroid effects. Prevention rests on anticoagulation protocols, sterile technique, image guidance, and incremental injection.
Emergency recognition
High-yield emergencies: epidural hematoma (progressive weakness, bowel/bladder dysfunction), epidural abscess (fever, focal tenderness, neurologic decline), and LAST (seizure, arrhythmia, cardiovascular collapse). Early recognition and escalation matter more than procedural detail.
Traps
- Underestimating anticoagulant effect timing.
- Attributing post-procedure fever or back pain to benign causes without considering infection.
- Missing LAST because symptoms are delayed.
- Forgetting to document informed consent and risk discussion.
Worked rule of thumb
Any new neurologic deficit after a neuraxial procedure is a surgical emergency until proven otherwise-image urgently and involve spine surgery. For LAST, stop injection, secure the airway, and give lipid emulsion per protocol.
Risk management
Document consent, contraindications, medications, and post-procedure instructions; consistent documentation is the strongest defense.