Case studyParaplegia after lumbosacral nerve root block: report of three cases☆,☆☆
Introduction
Lumbosacral nerve root blocks and epidural steroid injections are frequently used in the management of numerous degenerative conditions of the lumbar spine, including lumbar spinal stenosis, herniated lumbar intervertebral disc disease and facet arthropathy. Relatively few papers, however, have been published that address the complications associated with these interventions. A survey of large series of fluoroscopically guided epidural steroid injections reveals complication rates ranging from 0% to 9.6% [1]. The most commonly reported complication is headache, which is generally self-limited. Serious complications include epidural abscess, arachnoiditis, epidural hematoma, cerebrospinal fluid fistula and hypersensitivity reaction to injectate. Transient paraparesis resulting from epidural steroid injections was previously reported in a case involving inadvertent penetration of the thecal sac by an injection of local anesthetic [2]. We report two cases of paraplegia and one case of serious paraparesis in which neurologic function did not recover after performance of a lumbosacral nerve root block. In addition, we postulate the mechanisms of these neurological injuries. The injuries occurred at three different facilities, in the hands of two different injectionists, and in instances where penetration of the dura was not thought to have occurred. None of the patients had prior symptoms referable to the spinal cord. Magnetic resonance imaging (MRI) was performed within 24 hours of injury in each case revealed signal abnormality in the low thoracic spinal cord on T2-weighted imaging consistent with edema not present on MRIs of any of the three patients before the procedures.
Section snippets
Case 1
A 64-year-old woman presented with 2.5 months of complaints of low back pain, bilateral buttock and leg pain and numbness in her left leg after falling on her back. Four years before presentation, she had undergone laminectomy of L4–5 and a fusion with pedicle screw instrumentation to treat symptoms of progressive low back and leg pain from lumbar spinal stenosis and spondylolisthesis at this level. After surgery, she had good relief of symptoms for 2 years. She then began to complain of back
Discussion
Serious complications of lumbosacral steroid injections include epidural abscess 3, 4, 5, 6, epidural hematoma 7, 8 and hypersensitivity reactions to injectate 9, 10, 11. Neurological dysfunction has been reported as a late complication of dural penetration and subarachnoid injections with development of arachnoiditis 12, 13. Although transient paraparesis has been reported as an immediate sequelae of an intrathecal injection with local anesthetic [2], our report is the first to describe
Acknowledgements
The authors express their gratitude to Peter K. Nelson, MD, Assistant Professor of Radiology (Interventional Neuroradiology), New York University School of Medicine, for his guidance in understanding the relevant vascular anatomy and providing us with some of the images used in our figures.
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FDA Device/drug status: Approved for this indication (Depo-medrol, Celestone, Lidocaine).
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