Recovery After High-Dose Methylprednisolone and Delayed Evacuation

Abstract

Spinal epidural hematoma (SEH) is rare and not without serious sequelae. We report a patient who developed Brown-Séquard syndrome from SEH after fluoroscopic-guided cervical steroid injection and favorable response to methylprednisolone (MP). A 56-year-old man reported immediate sharp shooting pain to the upper extremities on introduction of epidural toughy needle. A total of 5 mL of 0.2% ropivacaine and 120 mg methylprednisolone acetate suspension was administered at the C6-7 interspace. Within half an hour, a neurologic deficit occurred at C7-8 and right Brown-Séquard syndrome developed. Once SEH was suspected (3 hours after onset of neurologic deficit), a protocol of high-dose MP intravenous infusion was initiated. Immediate incomplete recovery of motor, sensory, and sphincteric functions was noted within 30 minutes of infusion. Emergency spinal C6-T2 bilateral decompressive laminectomies and evacuation SEH were performed within an expected delay (10 hours from the onset of neurologic deficit). Fluoroscopic guidance does not take the place of adherence to meticulous technique. An unexplained neurologic deficit after invasive spinal procedures should raise the concern for SEH. Early recognition and emergent evacuation remain the mainstay management for SEH. This case suggests some neuroprotection from MP in cases of cervicothoracic cord compression secondary to traumatic SEH. When potential risks for SEH exist, it is advisable not to administer local anesthetic so as not to interfere with neurologic assessment and delaying the diagnosis.

Complications of Interlaminar Cervical Epidural Steroid Injections

“…26 Symptoms generally begin with a sharp shooting pain in the shoulder and upper limb ( Table 2). Potential risk factors implicated in developing epidural hematoma after ICESI include antiplatelet therapy, 27,28 multiple attempts due to technical difficulty, 29 and history of multiple cervical epidurals. 27,28 Several cases, however, have been reported in the absence of these risk factors.…”

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

“…1,3 Patients with neck or back pain undergoing ESIs or other spinal interventions may have significant spinal abnormalities including spinal stenosis, ligamentum flavum hypertrophy, spondylolisthesis, or spondylosis which may compact the epidural venous plexus within tight epidural spaces. 4,5 Moreover, patients after various spine surgeries may develop fibrous adhesions and scar tissue, thus further compromising the capacity of the epidural space and distorting the anatomy of the epidural vessels. The risk of bleeding is further increased in pain patients taking several concomitant medications with antiplatelet effects including NSAIDs, ASA, and SSRIs.…”

“…141,142 In addition, spinal hematomas have occurred after cervical ESIs in individuals taking non-aspirin NSAIDs. 4,143 Other studies examining the performance of lumbar epidurals for pregnancy have not demonstrated an increased risk of bleeding complications with aspirin. 144 The CLASP (Collaborative Low-Dose Aspirin Study in Pregnancy) did not show an increase in bleeding complications when performing epidurals for pregnancy in individuals taking 60 mg of enteric-coated aspirin daily.…”

“…[2][3][4] The current ASRA guidelines for the placement of epidural and spinal catheters do not recommend cessation of these antiplatelet agents for epidural procedures, nor do the guidelines differentiate between interventional pain procedures and perioperative regional anesthesia blocks. 1 …”

CT Fluoroscopy-Guided Cervical Interlaminar Steroid Injections: Safety, Technique, and Radiation Dose Parameters

“…[3][4][5] Some authors have suggested that the interlaminar approach for performing injections may be associated with a lower risk of catastrophic injury than the transforaminal approach, though spinal cord injury remains a possibility with either approach. [6][7][8][9] As such, many authors advocate limiting interlaminar epidural steroid injections to the C6-C7 level or below to reduce the risk of cord injury. 4,10,11 This restriction may necessarily limit the ability to deliver the greatest concentration of steroid to the site of pathology when it is above the C6-C7 level.…”