Presented at the 2012 AAPM Annual Meeting « Back

Lumbar Epidural Steroid Injection in a Patient with Von Willebrand's Disease

Pavan R. Telang, MD, pavan_telang@yahoo.com¹, Bruce M. Vrooman, MD², (1) St Rita's Medical Center, Lima, Ohio, (2) Cleveland Clinic, Cleveland, Ohio

Introduction: Numerous studies have established that neuraxial procedures can be performed in patients with Von Willebrand’s Disease (VWD), thus minimizing the risk of epidural hematoma. There is a paucity of data and guidelines regarding safety of interventional pain procedures for this patient population. We present a patient with a history of VWD requesting interventional therapy in the management of lumbar spinal stenosis. Methods: This is a case report of a 62-year-old female with VWD who presented with low back pain radiating down bilateral lower extremities to her calves. VWD was first diagnosed after postpartum hemorrhage and manifested as mucosal petechiae, ecchymosis, and bleeding following minor procedures. Treatment with DDAVP successfully prevented further complications. Patient has been asymptomatic for 10 years. Exam was negative for clinical signs of bleeding and revealed neurogenic claudication consistent with spinal stenosis. Coagulation tests were within normal limits. After consultation with her hematologist, she scheduled an infusion of DDAVP 20mcg/50ml NS completed 30 minutes before our procedure. After informed consent was obtained, she underwent an ESI at L5-S1. Results: Patient tolerated procedure well, was observed for neurologic monitoring and was instructed to report any changes in neurologic function immediately. Patient obtained symptomatic relief and had a repeat procedure subsequently. Conclusion: There are no definitive guidelines for patients with VWD undergoing neuraxial pain procedures. On a case-by-case basis, consultation with a hematologist and treatment of patients with DDAVP may minimize the risk of bleeding and subsequent complications. References: 1)Pasi KJ, Collins PW, Keeling DM, Brown SA, Cumming AM, Dolan GC, Hay CR, Hill FG, Laffan M, Peake IR. Management of von Willebrand disease: a guideline from the UK Haemophilia Centre Doctors’ Organization. Haemophilia 2004;10:218 –31. 2)Kessler CM. Diagnosis and treatment of von Willebrand disease: new perspectives and nuances. Haemophilia 2007 Dec;13 Suppl 5:3-14. 3)Choi S., Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg 2009 Aug;109(2):648-60.

Funding: None