Complications of epidural anaesthesia: What you should know before your cosmetic surgery
Complications associated with epidural anaesthesia range from a drop in blood pressure and headaches to rare, serious complications such as an epidural haematoma or nerve damage.
Complications of epidural anaesthesia
are adverse events following the administration of a local anaesthetic into the epidural space of the spine. Complications of epidural anaesthesia range from common, temporary symptoms such as a drop in blood pressure or headaches to rare, serious conditions such as epidural haematoma or nerve damage.
Table of Contents
Important note
This article is for information purposes only and is not a substitute for a medical diagnosis or advice. If you are unsure, or if you require a personalised treatment plan, it is essential that you consult a qualified specialist.
Anyone planning cosmetic surgery who is to receive an epidural anaesthetic is right to ask: what could go wrong, and who will bear the costs in the event of an emergency? The medical risks of epidural anaesthesia are well documented, but the financial implications for privately funded procedures are often not discussed. Both aspects are essential for thorough preparation.
What is an epidural anaesthetic (PDA)?
Key points at a glance:
- PDA = regional anaesthesia by injection into the epidural space of the spine
- Synonym: epidural anaesthesia; Abbreviation: PDA or EDA
- Active ingredients: local anaesthetics (bupivacaine, ropivacaine, lidocaine), some of which are combined with opioids
- Indications: labour pain, abdominal and pelvic surgery, post-operative pain management
- Difference from spinal anaesthesia: epidural anaesthesia acts outside the dura mater, whilst spinal anaesthesia acts directly within the cerebrospinal fluid space
The Epidural anaesthesia (abbreviated to PDA, also known as epidural anaesthesia) is a form of central regional anaesthesia. In this procedure, the anaesthetist inserts a thin Tuohy needle between two vertebral bodies to reach the epidural space. This space lies outside the dura mater, the outer covering of the spinal cord.
A fine catheter is inserted through the needle. The doctor injects the local anaesthetic through the catheter. The medication spreads into the epidural space, where it blocks the pain signals carried by the nerve roots passing through that area. This selectively blocks the sensation of pain in a specific part of the body. The anaesthetist confirms the correct placement by the ‘loss of resistance’: as soon as the needle reaches the epidural space, the resistance decreases as the syringe is advanced.
Epidural anaesthesia differs from spinal anaesthesia: with epidural anaesthesia, the local anaesthetic remains in the epidural space outside the dura. Spinal anaesthesia involves injecting directly into the cerebrospinal fluid space within the dura mater. Consequently, epidural anaesthesia takes longer to take effect, but can be continuously adjusted via the catheter — an advantage during longer procedures.
An overview of possible complications of epidural anaesthesia
Key points at a glance:
- Serious complications are rare, but they do occur and can have serious consequences
- Most common early complication: a drop in blood pressure (hypotension) caused by sympathetic blockade
- Most common technical complication: dura perforation, approx. 1 %
- The rarest, but most dangerous, complication: epidural haematoma, approx. 1 in 150,000
- It is a legal requirement to provide information about the risks prior to any procedure (Section 630e of the German Civil Code (BGB))
Complications associated with epidural anaesthesia can be divided into early and late complications, as well as technical and pharmacological complications. The following table summarises the most important complications and their approximate frequencies.
| Complication | Type | Approximate frequency | History |
|---|---|---|---|
| Low blood pressure (hypotension) | Early complication | up to 30 % | temporary, easily treatable |
| Duraperforation | Technical | approx. 1 % | postdural headache, rarely prolonged |
| Catheter migration | Technical | 1 – 3 % | depending on the location; repositioning if necessary |
| Accidental intrathecal injection | Early complication | less than 0.5 % | High spinal anaesthesia possible; emergency |
| Epidural haematoma | Late complication | approx. 1 : 150,000 | surgical emergency; risk of permanent damage |
| Epidural abscess | Late complication | approx. 1 : 100,000 | suitable for surgical treatment |
| Permanent neurological damage | Late complication | less than 1 : 10,000 | rarely, due to a haematoma or abscess |
| Allergic reaction to a local anaesthetic | Pharmacological | very rare | from skin redness to anaphylaxis |
According to a review article in the journal Regional Anaesthesia and Pain Medicine Serious, long-term neurological complications following epidural anaesthesia occur at a rate of less than 1 in 10,000. Most complications are temporary and can be effectively treated if detected early.
Early complications: hypotension, dural perforation and catheter migration
Key points at a glance:
- A drop in blood pressure is the most common early complication; it occurs within minutes of the injection
- Dural perforation causes characteristic headaches that subside when lying down
- Catheter migration can lead to accidental intravascular or intrathecal injection
- All early complications require immediate medical attention
Low blood pressure (hypotension): the most common early complication
Drop in blood pressure Following epidural anaesthesia, this is caused by the blockade of the sympathetic nervous system. The local anaesthetic blocks not only pain fibres but also sympathetic nerve fibres, which regulate vascular tone. The blood vessels dilate, peripheral resistance decreases, and blood pressure drops. Up to 30 % of all patients experience this effect to varying degrees.
Clinically, the drop in blood pressure manifests as dizziness, nausea, pallor and, in severe cases, brief loss of consciousness. Treatment involves the administration of intravenous fluids. If necessary, the doctor will administer vasoconstrictors such as ephedrine or phenylephrine. As the cause is known and predictable, experienced anaesthetists routinely prepare countermeasures.
With a thoracic anaesthetic in the thoracic spine region, the sympathetic block is more extensive than with a lumbar anaesthetic in the lumbar spine region. The anaesthesia team therefore monitors blood pressure and heart rate closely throughout the entire duration of the anaesthesia.
Deep puncture: when the needle penetrates too far
Duraperforation refers to the accidental puncture of the dura mater during needle placement. The incidence is approximately 1 in %, depending on the practitioner’s experience. As soon as the dura is perforated, cerebrospinal fluid (CSF) leaks out. This causes the pressure in the cerebrospinal fluid space to drop.
This drop in pressure causes what is known as the post-dural puncture headache: a severe, positional headache that worsens significantly when standing or sitting and eases considerably when lying down. This may be accompanied by neck stiffness, nausea, sensitivity to light and tinnitus. The headache begins 24–48 hours after the lumbar puncture.
As a conservative treatment, the doctor initially prescribes bed rest, plenty of fluids, caffeine and simple painkillers. If the headache persists for more than 48 hours or is very severe, the blood patch procedure (epidural blood patch) is used. In this procedure, the doctor draws a small amount of the patient’s own blood and injects it into the epidural space. The blood clots over the dural tear and seals it. According to the specialist literature, the success rate of this procedure is over 85 %.
Catheter migration: when the catheter changes position
Catheter migration refers to the unintentional displacement of the epidural catheter from its correct position in the epidural space. Catheter migration occurs in 1–3 % of all epidural catheters inserted. Different problems arise depending on the direction of the migration.
If the catheter migrates into an epidural blood vessel (intravascular migration), the local anaesthetic enters the bloodstream directly. This leads to systemic toxicity: numbness around the mouth, a metallic taste and dizziness are the first symptoms to appear. At higher concentrations, convulsions and cardiac arrhythmias may follow. This situation constitutes an anaesthetic emergency.
If the catheter migrates through the dura mater into the spinal canal (intrathecal migration), the local anaesthetic reaches the spinal cord directly. A dose calculated for the epidural space has a much stronger effect there. This can lead to what is known as high spinal anaesthesia, in which the respiratory muscles are paralysed. For this reason, the medical team administers a test dose before each epidural dose and monitors the effect closely.
Late complications: epidural haematoma, infections and neurological deficits
Key points at a glance:
- Epidural haematoma: a collection of blood in the epidural space, incidence approx. 1 in 150,000, surgical emergency
- Epidural abscess: bacterial infection, approx. 1 in 100,000; antibiotics plus surgery if necessary
- Nerve injury: rarely caused by direct mechanical damage
- Anterior spinal artery syndrome: very rare, ischaemia of the spinal cord with serious consequences
- Late complications occur hours to days after the procedure
Epidural haematoma: a rarer but more dangerous emergency
The Epidural haematoma — a collection of blood in the epidural space — is one of the most dangerous complications of epidural anaesthesia. The incidence is approximately 1 in 150,000. Nevertheless, the epidural haematoma is clinically significant: if left untreated, it compresses the spinal cord and can lead to permanent paralysis.
An epidural haematoma occurs when a blood vessel is damaged during the puncture or by the indwelling catheter, causing blood to seep into the epidural space. The risk increases significantly in patients taking blood thinners (anticoagulants) — such as Lixiana, Pradaxa or Eliquis. According to the guidelines of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), depending on the specific substance, a defined time interval must elapse between taking these medicines and the puncture.
Symptoms of an epidural haematoma typically develop within hours of the catheter being removed: severe, stabbing back pain, followed by increasing numbness and, eventually, paralysis in the legs and bladder. Time is of the essence — emergency surgical decompression must be carried out within 6–8 hours of the onset of symptoms to prevent permanent neurological damage.
Epidural abscess: an infection with the potential for serious complications
The Epidural abscess is a bacterial infection in the epidural space — often caused by Staphylococcus aureus. The incidence is approximately 1 in 100,000. An epidural abscess develops more slowly than an epidural haematoma, which makes early diagnosis more difficult.
Typical symptoms initially include fever and localised back pain at the puncture site, followed by radicular pain (pain running along a nerve root) and, finally, neurological deficits. Catheters left in place for longer than 72 hours also increase the risk of infection.
Treatment involves high-dose intravenous antibiotics. If neurological deficits have already developed, or if antibiotic therapy fails, surgical drainage is necessary. The prognosis depends largely on how quickly the diagnosis is made.
Nerve injuries and anterior spinal artery syndrome
Direct nerve injuries Complications caused by the epidural needle or catheter are rare. They can lead to temporary or permanent abnormal sensations, numbness or weakness in a specific area of the body. The risk increases if the patient reports pain or paraesthesia (tingling) during the puncture and the procedure is continued nonetheless — an indication of direct nerve irritation.
The Anterior spinal artery syndrome is a very rare, serious complication. It is caused by ischaemia (reduced blood flow) to the anterior parts of the spinal cord — due to vasospasms or vasoconstrictive additives (e.g. adrenaline) in the local anaesthetic. The clinical presentation involves paralysis of the legs whilst the sense of touch remains largely intact, as the posterior columns of the spinal cord continue to receive blood supply. The prognosis is poor.
Warning signs following an epidural: when immediate medical attention is required
Complications from epidural anaesthesia may still arise hours or days after the procedure. Almost all medical information lacks a checklist of warning signs that patients can easily understand — yet early intervention is crucial to the outcome.
Checklist of warning signs: symptoms following an epidural anaesthetic
- Severe, persistent headaches that ease when lying down and worsen when standing (post-dural puncture headache) — Contact a doctor
- Increasing numbness or tingling in the legs, buttocks or lower abdomen after the anaesthetic has worn off — IMMEDIATELY
- New-onset muscle weakness or signs of paralysis in the legs — IMMEDIATELY
- Severe tenderness or redness at the injection site on the back — Contact a doctor
- A fever above 38.5 °C accompanied by back pain (a possible sign of an epidural abscess) — IMMEDIATELY
- Loss of bladder or bowel control (urinary retention or incontinence) — IMMEDIATELY
- A sudden, severe drop in blood pressure, dizziness or confusion immediately after administration of the local anaesthetic — IMMEDIATELY
- Persistent back pain without neurological deficits more than 48 hours after the procedure — Contact a doctor
Note
This checklist is intended as a guide and is not a substitute for a medical diagnosis. Serious neurological complications, such as an epidural haematoma, require treatment within hours to prevent permanent damage. If you are unsure, always contact the hospital treating you or call the emergency services (112).
Seek immediate medical attention if:
Severe, position-dependent headaches (worse when standing up, better when lying down) — possible dura mater perforation New-onset numbness, tingling or weakness in the legs or feet after the anaesthetic has worn off Back pain at the puncture site that gets worse rather than better A temperature above 38.5 °C in the first few days after the procedure Urinary retention or uncontrollable urine leakage (bladder dysfunction) A feeling of pressure or swelling in the back at the level of the catheter Dizziness, a metallic taste or palpitations shortly after an epidural dose
Particularly following cosmetic procedures, where the patient is treated on an outpatient basis or at a cosmetic surgery clinic, aftercare is less intensive than in a hospital. This makes it particularly important to be alert to these warning signs.
Patients tend to underestimate back pain in the first few days following a procedure and attribute it to the position they were in during the operation. However, any pain that does not subside or is accompanied by a fever or numbness should be investigated by a doctor — without delay.
PDA in cosmetic procedures: Who bears the costs in the event of complications?
Privately funded cosmetic surgery — whether liposuction, rhinoplasty or breast surgery — carries a financial risk that medical information sources rarely address: Who pays if a complication arises after the procedure?
Myth
Statutory health insurance will cover all treatment costs if a complication arises with the epidural following my cosmetic surgery.
Fact
Statutory health insurance funds may reclaim the costs of follow-up treatment following privately funded cosmetic procedures. Patients must bear these costs themselves, unless they are covered by follow-up care insurance.
Section 52 of Book V of the Social Code (SGB V): Restriction of benefits in cases of contributory negligence
Myth
Serious complications such as an epidural haematoma following an epidural anaesthetic are so rare that they are of no practical significance.
Fact
Although serious complications are rare, they do occur: the incidence of an epidural haematoma is approximately 1 in 150,000, whilst a dural perforation occurs in about 1 % of cases. The resulting treatment costs can run into tens of thousands of euros.
Auroy et al., Anesthesiology 2002; Ruppen et al., Anesthesiology 2006
Myth
Epidural anaesthesia and spinal anaesthesia are the same procedure, with identical risks.
Fact
With epidural anaesthesia, the local anaesthetic remains in the epidural space outside the dura mater. With spinal anaesthesia, the anaesthetic is injected directly into the cerebrospinal fluid space. The onset of action, dosage and profile of complications differ in clinically significant ways.
DGAI Guidelines on Regional Anaesthesia Techniques, 2023
Under Section 52(2) of Book V of the Social Code (SGB V), statutory health insurance funds may reclaim treatment costs if damage to health is attributable to a procedure that was not medically necessary. If a complication arising from epidural anaesthesia occurs following cosmetic surgery — such as an epidural haematoma or an epidural abscess — and this requires emergency inpatient treatment, the health insurance fund may reclaim all or part of the costs from the insured person. The amounts involved can run into several thousand euros.
Financial protection in the event of PDA complications following cosmetic procedures
4beauty’s follow-up costs insurance covers medically necessary treatment arising as a result of the insured cosmetic procedure — including hospital stays in the event of serious complications. Coverage amounts to up to 300,000 euros; a policy for facelifts and liposuction starts from 35 euros per year. The insurance can be taken out up to 24 hours before the procedure.
It is important to understand that insurance covering consequential costs is no substitute for carefully choosing your surgeon and clinic. Having surgery performed by an experienced anaesthetist under sterile conditions, whilst correctly pausing the use of anticoagulant medication, significantly reduces the risk of complications. The insurance covers cases in which — despite all due care — an unwanted complication occurs. You can find out more about covered procedures in the Overview of treatments at 4beauty.
Frequently Asked Questions about Complications of Epidural Anaesthesia
Serious complications are rare. Epidural haematoma occurs at a rate of approximately 1 in 150,000, whilst epidural abscess occurs at a rate of approximately 1 in 100,000. Permanent neurological damage occurs in fewer than 1 in 10,000 cases of epidural anaesthesia. Temporary symptoms are more common: a drop in blood pressure occurs in up to 30 % of patients, and post-dural headaches following dural perforation in around 1 % — both conditions are easily treatable. Despite these low rates, the legally required information regarding all risks prior to the procedure (Section 630e of the German Civil Code (BGB)) is essential.
Permanent nerve damage caused by an epidural anaesthetic is possible, but rare. Direct damage to a nerve caused by the needle, an epidural haematoma that is not detected in time, or an epidural abscess can lead to permanent neurological deficits. The risk of permanent damage is less than 1 in 10,000. The time taken to treat the condition is crucial: an epidural haematoma must be surgically drained within 6–8 hours to prevent permanent damage. Anyone who notices new numbness or weakness following an epidural should seek medical help immediately.
Dural perforation refers to the accidental puncture of the dura mater, the outer protective covering of the spinal cord, during needle placement. Dural perforation occurs in approximately 1 % of all epidural anaesthesias and causes a typical positional headache: severe when sitting or standing, significantly better when lying down. Initial treatment is conservative (bed rest, fluids, caffeine, painkillers). In the event of severe or persistent headache, an epidural blood patch is used — the patient’s own blood is injected into the epidural space to seal the dural leak. The success rate is over 85 %.
In epidural anaesthesia, the local anaesthetic is injected into the epidural space outside the dura mater. In spinal anaesthesia, the doctor injects the anaesthetic directly into the cerebrospinal fluid space inside the dura. Spinal anaesthesia takes effect more quickly and is more reliable, but it is more difficult to adjust the dose. Epidural anaesthesia takes longer to take effect but can be continuously adjusted via a catheter and is therefore suitable for longer procedures and post-operative pain management. The two procedures differ in terms of their complication profiles: epidural anaesthesia carries a higher risk of catheter migration and epidural haematoma; spinal anaesthesia carries a higher risk of extensive sympathetic block.
In the case of privately funded cosmetic surgery, statutory health insurance funds may reclaim the costs of follow-up treatment — including in the event of complications arising from the anaesthesia used. This is based on Section 52(2) of the German Social Code, Book V (SGB V). The financial risk in the event of serious complications, such as an epidural haematoma or epidural abscess, can be considerable. Follow-up costs insurance covers medically necessary treatment following the insured procedure, up to 300,000 euros. Further information on the insurance terms and conditions can be found in the 4beauty FAQs.
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