Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports

Pain Med. 2009 Nov;10(8):1389-94. doi: 10.1111/j.1526-4637.2009.00728.x. Epub 2009 Oct 26.

Abstract

Objective: To present two case reports of a rare but devastating injury after image-guided, lumbar transforaminal injection of steroids, and to explore features in common with previously reported cases.

Background: Image (fluoroscopic and computed tomography [CT])-guided, lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicular pain. Complications associated with these procedures are rare, but can be severe.

Case reports: An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminal injection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided, right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patients developed bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediately after the procedures. Magnetic resonance imaging scans were consistent with spinal cord infarction. There was no evidence of intraspinal mass or hematoma.

Conclusion: These cases consolidate a pattern emerging in the literature. Distal cord and conus injury can occur following transforaminal injections at lumbar levels, whether injection is on the left or right. This conforms with the probability of radicular-medullary arteries forming an arteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, which promotes embolization in a radicular artery as the likely mechanism of injury. The risk of this complication can be reduced, and potentially eliminated, by the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminary injection of local anesthetic.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arteries / injuries
  • Arteries / pathology
  • Arteries / physiopathology
  • Embolism / chemically induced
  • Embolism / pathology
  • Embolism / physiopathology
  • Female
  • Fluoroscopy / methods*
  • Humans
  • Iatrogenic Disease / prevention & control
  • Infarction / chemically induced
  • Infarction / pathology
  • Infarction / physiopathology
  • Injections, Epidural / adverse effects
  • Injections, Epidural / methods
  • Leg / innervation
  • Leg / physiopathology
  • Low Back Pain / drug therapy*
  • Low Back Pain / physiopathology
  • Lumbar Vertebrae / diagnostic imaging
  • Lumbar Vertebrae / pathology
  • Lumbar Vertebrae / surgery*
  • Magnetic Resonance Imaging
  • Male
  • Methylprednisolone / administration & dosage
  • Methylprednisolone / adverse effects
  • Paraplegia / chemically induced*
  • Paraplegia / physiopathology
  • Postoperative Complications / etiology
  • Postoperative Complications / physiopathology
  • Postoperative Complications / prevention & control
  • Radiculopathy / drug therapy*
  • Radiculopathy / physiopathology
  • Spinal Cord Injuries / chemically induced
  • Spinal Cord Injuries / pathology
  • Spinal Cord Injuries / physiopathology
  • Steroids / administration & dosage
  • Steroids / adverse effects*
  • Steroids / chemistry
  • Surgery, Computer-Assisted / adverse effects
  • Surgery, Computer-Assisted / methods
  • Urinary Bladder, Neurogenic / chemically induced
  • Urinary Bladder, Neurogenic / physiopathology
  • Zygapophyseal Joint / drug effects
  • Zygapophyseal Joint / physiopathology

Substances

  • Steroids
  • Methylprednisolone