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  • Case Series: Intramedullary Air and Epidural Hematoma following Cervical Injection: Rare Causes of Spinal Cord Injury

    Final Number:

    Jonathan Pace MD; Gabriel Alexander Smith MD; Salim Hayek MD; Jonathan P. Miller MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Chronic neck and back pain are highly prevalent and are cited as the most common reason for time missed from work. Interventional pain procedures such as epidural steroid injections have been used in appropriately selected patients. Complications of epidural steroid injections include epidural hematoma, epidural infection, paraplegia, and death. We present two cases, one of acute epidural hematoma and the other of intramedullary air injection during epidural steroid injection.

    Methods: Case Series

    Results: Case 1: An 86 year old man with history of atrial fibrillation on Coumadin underwent fluoroscopic guidance midline C6-7 epidural steroid injection for chronic neck pain, utilizing loss-of-resistance technique (Figure 1). Patient developed acute-onset weakness and diminished sensation in all 4 extremities. An emergent MRI demonstrated acute epidural hematoma (Figure 2). Patient underwent decompression and was subsequently discharged to rehab. Case 2: An 83 year old female with remote history of C6-7 ACDF presents with intractable neck pain and right upper extremity radiculopathy. Limited systemic monitored anesthesia was provided and fluoroscopic x-ray was used to confirm localization for the injection. After completion of the procedure, she developed acute plegia of the left arm and both legs. An MRI of the cervical spine demonstrated an intramedullary hypointensity on T1- and T2-weighted sequences extending from C2-6 (Figure 3), consistent with intramedullary air. Within the next few hours, the patient recovered all strength in her lower extremities; however, she remained plegic without sensation in her left upper extremity with a left partial horner’s syndrome. Patient was discharged to rehab.

    Conclusions: This study highlights the importance of mastery of the anatomical considerations and radiographic localization of the epidural space during fluoroscopic injections. It is critical that all patients with post-procedural neurological deficits following epidural steroid injection be evaluated with imaging as immediate surgical decompression can lead to neurological recovery in select cases.

    Patient Care: Our research will improve patient care by raising awareness of the potentially serious side effects of invasive pain management procedures, including epidural injections, with the aim of preventing similar incidents in the future. This presentation also stresses the importance of obtaining immediate imaging, as select cases may benefit from immediate surgical intervention

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss serious side effects of epidural injections, 2) Discuss conservative and invasive means for treating chronic pain, 3) Understand anatomic landmarks of the cervical spine and limitations of fluoroscopic guidance for ensuring proper positioning during epidural injection

    References: 1. Anderberg L, Annertz M, Persson L, Brandt L, Säveland H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J 2007; 16: 321-8. 2. Brouwers, P. J., et al. "A Cervical Anterior Spinal Artery Syndrome After Diagnostic 0Blockade of the Right C6-Nerve Root." Pain 91.3 (2001): 397-9. Print. 3. Carragee, E. J., et al. "Treatment of Neck Pain: Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders." Journal of manipulative and physiological therapeutics 32.2 Suppl (2009): S176-93. Print. 4. Heckmann, J. G., et al. "Transient Tetraplegia After Cervical Facet Joint Injection for Chronic Neck Pain Administered without Imaging Guidance." Clinical neurology and neurosurgery 108.7 (2006): 709-11. Print. 5. Hirpara, K. M., et al. "Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis." Advances in orthopedics 2012 (2012): 294857. Print. 6. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976). 1998 Oct 1;23(19):2137-42; discussion 2141-2. 7. Huston, C. W. "Cervical Epidural Steroid Injections in the Management of Cervical Radiculitis: Interlaminar Versus Transforaminal. A Review." Current reviews in musculoskeletal medicine 2.1 (2009): 30-42. Print. 8. Kim, T. S., et al. "Air Bubbles Mimic Disc Herniation in MRI After Cervical Epidural Block." The Korean journal of pain 23.3 (2010): 202-6. Print. 9. Lee, J. H., et al. "Spinal Cord Injury Produced by Direct Damage during Cervical Transforaminal Epidural Injection." Regional anesthesia and pain medicine 33.4 (2008): 377-9. Print. 10. Manchikanti, L., et al. "Complications of Fluoroscopically Directed Facet Joint Nerve Blocks: A Prospective Evaluation of 7,500 Episodes with 43,000 Nerve Blocks." Pain physician 15.2 (2012): E143-50. Print. 11. Mehta, S., A. A. Khalil, and A. Alshekhlee. "Air Myelopathy Following a Cervical Epidural Injection." Pain medicine (Malden, Mass.) 11.11 (2010): 1678-9. Print. 12. Moon JY, Lee PB, Hahm FS, Kim YC, Choi JB. Cervical epidural pressure measurement: comparison in the prone and sitting positions. Anesthesiology 113.3 (2010): 666-71. 13. Murphy, D. R., and E. L. Hurwitz. "Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain." Chiropractic & manual therapies 19.1 (2011): 19,709X-19-19. Print. 14. Rathmell JP, Kehlet H. Do we have the tools to prevent phantom limb pain? Anesthesiology 114.5 (2011): 1021-4 15. Schoenfeld AJ, George AA, Bader JO, Caram PM. Incidence and Epidemiology of Cervical Radiculopathy in the United States Military: 2000 to 2009. J Spinal Disord Tech 2011 Mar 21 16. Stav A, Ovadia L, Sternberg A, Kaadan M, Weksler N. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand 1993; 37: 562-6. 17. Wallace MA. et al., Complications of Cervical Selective Nerve Root Blocks Performed with Fluoroscopic Guidance Am. J. Roentgenol., May 2007; 188: 1218 - 1221.

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