Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature

Abstract

The high rate of French cases when compared to the literature might arise from the almost exclusive use of prednisolone acetate, a molecule with a high tendency to coalesce in macro-aggregates, putting the spinal cord at risk of arterial supply embolization.

Extraforaminal needle tip position reduces risk of intravascular injection in CT-fluoroscopic lumbar transforaminal epidural steroid injections

“…There are 19 case reports of spinal cord injury following conventional fluoroscopic-or CT-guided thoracolumbar TFESI (3,4,6,8,16,(23)(24)(25)(26)(27)(28)(29) [(although the complication is known to be underreported due to its medicolegal implications (8)]. Review of the imaging and procedural descriptions for these 19 case reports shows a foraminal needle location, sometimes deep within the neural foramen, in 7 of these cases; in the remaining 12, insufficient information is provided to determine needle depth relative to the targeted neural foramen (3,29).…”

Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety

“…The injected steroid must have a sufficient volume to correctly fill the epidural space, the diluent being a neutral ineffective fluid. For safety reasons, the steroid chosen must have the least tendency to coalesce [70]. The only way to clearly distinguish the efficacy of the procedure from a simple placebo effect is through the use of a sham ineffective control, such as a local intramuscular ineffective injection, simulating an epidural injection on a blinded randomized patient.…”

“…Since 2002, 12 such cases have been observed. They have been analyzed in detail by Wybier et al [70]. The clinical pattern is similar in all cases: within a few minutes after the procedures, acute abdominal and leg pain are followed by a complete sensorimotor deficit of the lower limbs.…”

Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update

“…Death as well as infarction of cerebellum, brain stem, thalamus, cervical, and lumbar spinal cord have been reported after cervical and lumbar epidural injections, either by an interlaminar or transforaminal approach [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. In the literature, all 17 thoracolumbar spinal cord infarctions related to lumbosacral epidural steroid injection were associated with particulate steroids whereas no case of paraplegia was described after image-guided epidural injection of dexamethasone [16][17][18][19][20][21][22][23][24][25][26].…”

“…In the literature, all 17 thoracolumbar spinal cord infarctions related to lumbosacral epidural steroid injection were associated with particulate steroids whereas no case of paraplegia was described after image-guided epidural injection of dexamethasone [16][17][18][19][20][21][22][23][24][25][26]. It has to be noted that the damage to the spinal cord commonly occurred several segments cranial to the lumbosacral injection site: for instance, in the case reported by Chang Chien et al, a transforaminal epidural steroid injection was performed at the level L5-S1, but subsequently spinal cord infarction on MRI was diagnosed between the T6 and the T9-T10 level [25].…”