Spinal intracord injection damage during interlaminar cervical epidural steroid injection: a case report and review of the literature (2024)

Background

Interlaminar cervical epidural steroid injection are commonly performed in the practice of interventional pain medicine. Spinal cord damage following injection into the substance of the cord is a known complication of this procedure. Only four cases have been reported in the literature, all of which have been associated with poor prognosis.

Case description

A 47-year-old Chinese woman with chronic neck pain underwent interlaminar cervical epidural steroid injection in C5–C6 space under local anesthesia using C-arm fluoroscopic guidance. Immediately after the procedure, she experienced loss of consciousness and quadriplegia. She was subsequently transferred to the orthopedic department and treated for 2 weeks before being transferred to the rehabilitation department for additional 2 weeks. The magnetic resonance imaging performed 8 hours after the injection revealed hyperintensity on T2-weighted images in the spinal cord extending from C4 to C6 vertebrae, with central cord swelling toward the right. She received standard methylprednisolone therapy within 8 hours of the injury, as well as hyperbaric oxygen treatment and acupuncture during her hospitalization. Her neurological symptoms gradually improved, ultimately demonstrating normal motor strength in all four extremities, with slight numbness in the right arm and normal spinal cord morphology on magnetic resonance imaging at the 8-month follow-up.

Conclusion

This case represents a rare instance of spinal intracord injection damage during ICESI resulting in quadriplegia, with subsequent favorable neurological improvement.

A 47-year-old Chinese woman suffering from chronic neck pain underwent ICESI in C5–C6 space. The procedure was performed by the fellowship-trained pain management specialist at the outpatient surgical center. The following account was recorded by the specialist. The patient was positioned prone, and local anesthesia with 2ml 1% lidocaine was administered. Under fluoroscopy, the epidural space was located with an 18-G Tuohy needle at the C5–C6 interspace using a loss of resistance technique after confirming a negative aspiration test for air, blood, and cerebrospinal fluid. A lateral approach revealed the tip of the needle at the interlaminar line. The procedure noted that the puncture was executed without difficulty. The patient exhibited good mobile without complaints. A volume of 1ml, consisting of 1ml of a mixture of Diprospan (contains 5mg betamethasone dipropionateand and 2mg betamethasone disodium phosphate) and 1ml of 2% lidocaine, was injected slowly, with additional aspirations during and after the injection. Immediately following the injection, the patient experienced tingling in his hands and legs for a few minutes, followed by loss of consciousness and quadriplegia.

She was intubated for 30 minutes and subsequently transferred to our orthopedic department for treatment under the care of the investigators group. While in the intensive care unit, she remained unresponsive. Her heart rate, blood pressure, and oxygen saturation (SpO₂) were noted to be 70 beats per minute, 90/60mmHg, and 92% respectively. Two hours post-injection, her consciousness returned to normal, and some function had returned to her left arm and leg. However, she remained unable to move right upper and lower extremities voluntarily or in response to painful stimuli. Deep tendon reflexes of four extremities were noted to be absent. Motor strength was 3/5 in her left extremities, 0/5 in the right upper extremities, and 2/5 in the right lower extremities. Her anal sphincter tone was found to be normal. A magnetic resonance imaging (MRI) performed 8 hours after the injection revealed hyperintensity on T2-weighted images in the spinal cord extending from C4 to C6 vertebrae, with central cord swelling toward the right (Fig.1).

The principal diagnosis was quadriparesis, secondary to cervical spinal intracord injection. Due to the nature of the injury, the standard methylprednisolone protocol [9] was initiated within 8hours of the injury. Hyperbaric oxygen treatment and acupuncture also performed during her hospitalization (14days). A neurologic examination 2weeks post-procedure revealed significant new changes, including normal sensory function in the left extremities, numbness in the right arm, 4/4 of deep tendon reflexes in all four extremities, 5/5 of motor strength in the left extremities, and 4/5 of motor strength in the right extremities. After transfer to rehabilitation department for an additional 2weeks, her motor strength of right extremities improved to 5/5, but there was no change in the numbness of right arm. An MRI taken 5months later showed normal spinal cord morphology in sagittal T2 signal intensity, but axial low T1 signal intensity within spinal cord on the right side (Fig.2). At the 8-months follow-up, normal motor strength was observed in all four extremities, with slight numbness of right arm, and normal spinal cord morphology in MRI (Fig.3).

Cervical intracord injection damage is a severe complication associated with ICESI procedure. Apart from the present case, only five patients having been reported (Table1) [6,7,8]. Interestingly, these five cases have not been reported by ICESI procedure specialists, but by the doctors from transferred hospitals or departments. These cases also exhibited different MRI, clinical symptoms, and prognosis.

The majority of MRIs showed T2 high intensity, which is associated with the cause of injury, except for one case that showed no signal change in spinal cord. The cause of injury included three types: direct spinal cord injury from the needle, intracord occupying space, and injury from the drug itself. First, Bose [7] reported a case of quadriparesis with no change in signal characteristics on MRI in the spinal cord. The only explanation is needle interventions. Second, the other four cases (including our case) presented instant T2 high intensity within the intracord, indicating the cord edema from liquid injection. It is suggested that a certain volume of liquid had caused intracord occupying space. Third, whether the drug itself was the cause of the injury is unknown. There were warnings about the use of methylprednisolone (containing polyethylene glycol) in proximity to neural tissue due to the potential neurotoxicity of polyethylene glycol [10]. However, the immediacy of the injury and instant T2 high intensity within the intracord associated with this injection do not support the likelihood that neurotoxicity from methylprednisolone caused the adverse effects, though it is conceivable that neurotoxicity could be a factor that limited recovery.

The clinical symptoms, including onset, general symptoms, segmental neural symptoms, and quadriplegia, have been reported differently. Only Hodges reported delayed onset neural symptoms 24hours after ICESI [6]. The other four cases (including the present case) experienced symptoms immediately after the injection or upon awakening from sedation. Neural symptoms were reported in all cases, including nerve root motor weakness, numbness, and paresthesias (Table1) [6,7,8]. Quadriplegia was observed in Bose’s reported case [7] and our case. The reasons for the difference in onset and extent of neural symptoms are unclear, but maybe related to the drug itself and the volume of injected liquid.

Although all reported cases received prompt diagnosis and standard treatment, including cervical decompression surgery in one case [6], the prognosis varied. Permanent quadriplegia and no improvement were reported in two patients who had undergone the standard methylprednisoloe protocol and physical therapy [6, 7]. Some improvement with residual neuropathic pain also reported in the patients with moderate MRI T2 high intensity [6, 8]. However, the present patient, despite experiencing quadriplegia, being unconscious, and displaying severe MRI T2 high intensity, recovered remarkably well, with only slight residual numbness right arm and nearly normal MRI signal characteristics. It is unknown whether she benefited from the minor needle injuries, hyperbaric oxygen treatment, and acupuncture.

Several authors have emphasized the guidelines regarding sedation and fluorography procedure to maximizing patient safety during potentially dangerous procedures such as ICESI [6, 8, 11]. Accessing the cervical epidural space is typically not painful if the skin and underlying tissue are adequately anesthetized. Hodges reported two cases and Landers reported one case where intravenous anesthesia was used, contrary the guidelines [6, 8, 11]. However, in the case reported by Bose [7], the present case, and a reported case of thoracic IESI [12], either no sedation or only local anesthetic was used, yet spinal cord injury still occurred. Therefore, it is recommended to pay more attention to or adhere to fluoroscopy procedure guidelines. The placement of a needle should be documented on at least two imaging planes, typically an anterior–posterior (AP) view and a lateral view or oblique view, to accurately determine the needle was location [13].

ICESI:

Interlaminar cervical epidural steroid injection

SCI:

Spinal cord injury

MRI:

Magnetic resonance imaging

Authors and Affiliations

1. Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, Shapingba District, Chongqing, 400037, China

   Rongmei Li,Chunmei Luo&Zhengfeng Zhang

Contributions

RL carried out data collection and manuscript writing; CL carried out data collection and paper review; ZZ carried out research design and manuscript writing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Zhengfeng Zhang.

Ethics approval and consent to participate

The privacy of the patient was considered, and the manuscript does not include any identifying information.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no conflicts of interest associated with this manuscript.

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