Paraplegia After Thoracic Epidural Steroid Injection

Loomba, Vivek; Kaveeshvar, Hirsh; Dwivedi, Samvid

doi:10.1213/xaa.0000000000000402

Cited by 13 publications

(12 citation statements)

References 11 publications

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“…Spinal epidural hematomas are exceedingly rare complications with potentially devastating long-term consequences. Previous case reports detailing spinal epidural hematomas in patients receiving epidural steroid injections often involve injecting patients who are either on anticoagulants or have spinal stenosis (6)(7)(8)(9). Generally, anticoagulants (such as warfarin) are discontinued in patients prior to the epidural steroid injection and normal international normalized ratio verified as advocated by the American Society of Regional Anesthesia and Pain Medicine and the American Society of Interventional Pain Physicians (4,5).…”

Section: Discussionmentioning

confidence: 99%

Spontaneous Resolution of Presumed Acute Epidural Hematoma Formation After Lumbar Epidural Steroid Injection

Lam

2017

PMCR

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Epidural steroid injections are interventional pain procedures often used to treat lumbar radicular pain. The most serious complication of this procedure is the formation of a spinal epidural hematoma, which can result in profound permanent neurologic deficits if left untreated. A 76-year-old woman with mild lumbar spinal stenosis (L4-L5, L5-S1) and lumbar dextroscoliosis, previously on 81mg of aspirin daily (discontinued at 14 days prior to procedure) and not on anticoagulation therapy, underwent a lumbar epidural steroid injection (T12-L1). Post-procedurally, she developed bilateral leg paralysis. A magnetic resonance imaging (MRI) study revealed a fluid collection concerning for hematoma. Neurosurgery was consulted, but at the time of evaluation, she had near resolution of her presenting symptoms and the decision was made to monitor her for 48 hours. Three months after discharge, MRI revealed no persistent symptoms or radiographic evidence of sequelae from epidural hematoma. The frequency of spinal epidural hematomas after epidural steroid injections is unknown. This patient did not have traditional risk factors of severe spinal stenosis or the use of anticoagulant or antiplatelet agents. A radiographic fluid collection was seen, which may represent blood or persistent injectate. A formal surgical diagnosis was not obtained, as her symptoms spontaneously improved without further need for intervention. We report the first case of presumed persistent injectate compression of the lumbar spinal cord, resulting in bilateral lower extremity weakness in a patient with dextroscoliosis, mimicking spinal epidural hematoma with spontaneous resolution without intervention. Key words: Epidural steroid injection, spinal epidural hematoma, dextroscoliosis, lumbar radiculopathy, spinal stenosis, lower extremity paralysis

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Section: Discussionmentioning

confidence: 99%

Spontaneous Resolution of Presumed Acute Epidural Hematoma Formation After Lumbar Epidural Steroid Injection

Lam

2017

PMCR

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“…New challenges arise when practitioners perform interventional procedures on patients who are anticoagulated. Even with adherence to guidelines for performing neuroaxial injections in the setting of anticoagulants, patients may develop an epidural hematoma and paraplegia after thoracic epidural steroid injection ( 32 ). Combination of LAs and steroids improves postoperative analgesia.…”

Section: Steroidsmentioning

confidence: 99%

Local Anesthetics and Steroids: Contraindications and Complications - Clinical Update

Šimurina

Mraović

Župčić

et al. 2019

ACC

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SUMMARYThe objective of this clinical update, based on recently published literature, was to discuss incidence and characteristics of the most relevant clinical adverse effects associated with local anesthetic and steroid use in regional anesthesia and treatment of acute or chronic pain. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from 2015 to 2018 was performed. This narrative review provides anesthesia practitioners with updated evidences on complications and contraindications of local anesthetic and steroid use with emphasis on current points of view regarding prevention, early diagnosis and treatment of adverse events.

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“…Such hematomas can gradually increase in size and cause compression to the neural structures and subsequent onset of weakness and decreased sensation, which can impede driving and increase risk both to the patient and others in close proximity. While the onset of sensorimotor impairment due to a developing epidural hematoma may occur within minutes [23,24] or take more than a day [25][26][27][28][29][30][31][32], there are case reports of onset in the time-frame of discharge after injection in a typical clinic setting (i.e. 20-30 minutes) [33,34].…”

Section: Sensorimotor Impairmentmentioning

confidence: 99%

Driving After an Epidural Steroid Injection Without Sedation

2018

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Myth: Driving is safe after an epidural steroid injection (ESI) procedure without the use of sedation. Fact: Driving safety is potentially compromised by the use of local anesthetic included in the epidural injectate even if sedation is not used during the procedure. Further, rare cases of delayed-onset visual and sensorimotor impairments, independent of the effects of local anesthetic, have been associated with ESI. Therefore, clinicians may consider rescheduling an ESI procedure if the patient does not have a driver. Key Points: • Temporary sensorimotor impairment is expected in a subset of patients who undergo ESI with local anesthetic included in the epidural injectate, and delayed-onset sensorimotor block and loss of consciousness may occur following unintentional subdural local anesthetic injection. • The risk of delayed-onset visual impairment related to retinal hemorrhage may be mitigated by slow, low volume injection. • The risk of spinal hematoma with subsequent sensorimotor impairment may be mitigated by transforaminal access in accordance with clinical practice guidelines [1,2].

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Paraplegia After Thoracic Epidural Steroid Injection

Cited by 13 publications

References 11 publications

Spontaneous Resolution of Presumed Acute Epidural Hematoma Formation After Lumbar Epidural Steroid Injection

Spontaneous Resolution of Presumed Acute Epidural Hematoma Formation After Lumbar Epidural Steroid Injection

Local Anesthetics and Steroids: Contraindications and Complications - Clinical Update

Driving After an Epidural Steroid Injection Without Sedation

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