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| 22KS-017 |
Intradural extramedullary hematoma after cervical epidural injection : A case report
Department of
Anesthesiology and Pain medicine, Samsung Medical Center, Sungkyunkwan
University School of Medicine, Seoul, Korea
Introduction
Although fluoroscopic guided cervical epidural steroid injection (CESI) is widely used in the management of cervical radiculopathy, it is important to assess the potential complications associated with this procedure. We report a case of intradural extramedullary (IDEM) hematoma after cervical epidural injection.
Case
A 71-year-old male visited the pain clinic with numbness and pain from the neck to the right arm, and was diagnosed with cervical radiculopathy. Magnetic resonance imaging (MRI) showed disc degeneration and foraminal stenosis at C5-6 level. He had a medical history of hypertension, and physical examination and laboratory test was all normal. We planned to perform CESI in the C6/7 interlaminar space. When the needle tip reached the epidural space using loss of resistance technique, we administered a contrast agent to confirm the space by fluoroscopy. At that time, he complained of paresthesia on the right leg, then, we stopped the procedure. He was discharged without any neurologic complications.
Two weeks later, the patient presented to the emergency room with severe headache (VAS score of 8). MRI showed IDEM hematoma at C7-T1 level with intraventricular hematoma (IVH) and subarachnoid hemorrhage (SAH) in sacral lesion (Fig.1). Computed tomography (CT) angiography was performed to rule out cerebral aneurysm. Cerebrospinal fluid analysis revealed 627,000 red blood cells/mm3 and 797 white blood cells/mm3, meaning of SAH. Because the patient did not have neurologic deficits, he was admitted to the general ward for close observation.
However, a week later, his right upper extremity showed motor weakness of grade 2~3. The follow up MRI showed increase in the size of the IDEM hematoma, extending to C6-T4, with cord compression and myelopathy at C5-7 (Fig. 2). Emergent surgical evacuation of the hematoma was done. During the follow-up of two months, he regained his full muscle power except his right finger abductor (Right/Left=3- /5).
Conclusion
Based on the anatomical predilection, spinal cord abscess, vascular malformation, bleeding derived from use of anticoagulant medication, tumor invasion or trauma are well-documented causes of IDEM hematoma. Although incidence of IDEM hematoma is low, we believe that the continued reporting of such complications is vital in that early recognition and treatment can improve prognosis.
Although fluoroscopic guided cervical epidural steroid injection (CESI) is widely used in the management of cervical radiculopathy, it is important to assess the potential complications associated with this procedure. We report a case of intradural extramedullary (IDEM) hematoma after cervical epidural injection.
Case
A 71-year-old male visited the pain clinic with numbness and pain from the neck to the right arm, and was diagnosed with cervical radiculopathy. Magnetic resonance imaging (MRI) showed disc degeneration and foraminal stenosis at C5-6 level. He had a medical history of hypertension, and physical examination and laboratory test was all normal. We planned to perform CESI in the C6/7 interlaminar space. When the needle tip reached the epidural space using loss of resistance technique, we administered a contrast agent to confirm the space by fluoroscopy. At that time, he complained of paresthesia on the right leg, then, we stopped the procedure. He was discharged without any neurologic complications.
Two weeks later, the patient presented to the emergency room with severe headache (VAS score of 8). MRI showed IDEM hematoma at C7-T1 level with intraventricular hematoma (IVH) and subarachnoid hemorrhage (SAH) in sacral lesion (Fig.1). Computed tomography (CT) angiography was performed to rule out cerebral aneurysm. Cerebrospinal fluid analysis revealed 627,000 red blood cells/mm3 and 797 white blood cells/mm3, meaning of SAH. Because the patient did not have neurologic deficits, he was admitted to the general ward for close observation.
However, a week later, his right upper extremity showed motor weakness of grade 2~3. The follow up MRI showed increase in the size of the IDEM hematoma, extending to C6-T4, with cord compression and myelopathy at C5-7 (Fig. 2). Emergent surgical evacuation of the hematoma was done. During the follow-up of two months, he regained his full muscle power except his right finger abductor (Right/Left=3- /5).
Conclusion
Based on the anatomical predilection, spinal cord abscess, vascular malformation, bleeding derived from use of anticoagulant medication, tumor invasion or trauma are well-documented causes of IDEM hematoma. Although incidence of IDEM hematoma is low, we believe that the continued reporting of such complications is vital in that early recognition and treatment can improve prognosis.
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