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| 22KS-011 |
Spinal cord injury and postdural puncture headache after cervical epidural steroid injection: A case report
Department of Anesthesiology
and Pain Medicine, Korea University Medical Center, Guro Hospital
Background
Cervical interlaminar epidural steroid injection (CIESI) is increasingly being used as a medical interventional treatment for pain originating from the cervical spine. In particular, as the number of patients complaining of cervical radicular pain increases with aging, the frequency of CESI treatment is also increasing. However, during CIESI, serious neurological complications may occur because of direct nerve damage due to inappropriate needle placement.
Case report
A 35-year-old woman with no specific medical history presented with posterior neck pain radiating in the left upper arm, and left C6 nerve impingement due to a left foraminal extrusion at the C5/6 level on cervical magnetic resonance imaging (MRI). She underwent cervical epidural steroid injection under fluoroscopy using the left C5/6 interlaminar approach at another hospital. Immediately post-procedure, the patient experienced dizziness, decreased blood pressure, left upper arm motor weakness, and sensory loss. She visited our emergency department with a postdural puncture headache (PDPH) that worsened from the evening of the procedure. Cervical spine MRI performed after admission showed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a spinal cord injury was diagnosed. The patient\'s PDPH spontaneously improved after 48 h. However, decreased abduction of the left fifth finger and sensory loss in the back of the left hand persisted until 6 months post-procedure. On follow-up MRI performed 6-months post-procedure, the T2 high signal intensity in the left central intramedullary region was decreased compared with that observed previously; however, cord swelling was still present. Furthermore, left C7/8 radiculopathy with acute denervation activity was confirmed on electromyography performed 6-months post-procedure.
Conclusions
The use of fluoroscopy does not guarantee the prevention of intrathecal perforation or spinal cord penetration during epidural steroid injections. Moreover, persistent neurological deficits may occur, particularly with intrathecal perforation or intrathecal drug administration during CIESI. Therefore, we recommend performing CIESI at the C6/7 or C7/T1 level, which has a relatively large epidural space, rather than at the C5/6 or higher level.
Cervical interlaminar epidural steroid injection (CIESI) is increasingly being used as a medical interventional treatment for pain originating from the cervical spine. In particular, as the number of patients complaining of cervical radicular pain increases with aging, the frequency of CESI treatment is also increasing. However, during CIESI, serious neurological complications may occur because of direct nerve damage due to inappropriate needle placement.
Case report
A 35-year-old woman with no specific medical history presented with posterior neck pain radiating in the left upper arm, and left C6 nerve impingement due to a left foraminal extrusion at the C5/6 level on cervical magnetic resonance imaging (MRI). She underwent cervical epidural steroid injection under fluoroscopy using the left C5/6 interlaminar approach at another hospital. Immediately post-procedure, the patient experienced dizziness, decreased blood pressure, left upper arm motor weakness, and sensory loss. She visited our emergency department with a postdural puncture headache (PDPH) that worsened from the evening of the procedure. Cervical spine MRI performed after admission showed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a spinal cord injury was diagnosed. The patient\'s PDPH spontaneously improved after 48 h. However, decreased abduction of the left fifth finger and sensory loss in the back of the left hand persisted until 6 months post-procedure. On follow-up MRI performed 6-months post-procedure, the T2 high signal intensity in the left central intramedullary region was decreased compared with that observed previously; however, cord swelling was still present. Furthermore, left C7/8 radiculopathy with acute denervation activity was confirmed on electromyography performed 6-months post-procedure.
Conclusions
The use of fluoroscopy does not guarantee the prevention of intrathecal perforation or spinal cord penetration during epidural steroid injections. Moreover, persistent neurological deficits may occur, particularly with intrathecal perforation or intrathecal drug administration during CIESI. Therefore, we recommend performing CIESI at the C6/7 or C7/T1 level, which has a relatively large epidural space, rather than at the C5/6 or higher level.
