Acute Cauda Equina Syndrome Caused by Epidural Steroid Injection in the Setting of a Spinal Dural Arteriovenous Fistula

Kaitlyn L Slimp,Jeffrey A Nielson,Roy L Johnson,Lara N Martinez

doi:10.7759/cureus.21752

Abstract

We present a case of acute cauda equina syndrome caused by an epidural steroid injection in the setting of a previously undiagnosed spinal dural arteriovenous fistula (SDAVF). Our patient was a 61-year-old man who presented to the emergency department with low back pain, inability to walk, paresthesias of his bilateral lower extremities, bowel and bladder incontinence, and saddle anesthesia. Physical examination revealed weakness and decreased sensation of the lower extremities as well as poor rectal tone and urinary retention. Magnetic resonance imaging (MRI) revealed evidence of spinal cord edema in the T9-10 region and a probable SDAVF with secondary distal thoracic cord ischemia. This case highlights the importance of prompt recognition of cauda equina syndrome in the emergency department, expedient imaging, and efficient transfers of care, which allowed this patient to quickly undergo necessary surgery that led to an almost complete recovery. It also highlights the importance of recognizing subtle changes on lumbar MRI.

Highlights

Spinal dural arteriovenous fistula (SDAVF) is a rare condition in which an abnormal connection exists between the arteries and veins surrounding the spinal cord [1]
We present a case of a 61-year-old Caucasian patient with spinal degenerative disease and an unrecognized SDAFV who had sudden onset of cauda equina syndrome following an interlaminar, fluoroscopy-guided epidural steroid injection
Bladder scan revealed urinary retention with greater than 500 cc of urine drained after Foley catheterization

Summary

Introduction

Spinal dural arteriovenous fistula (SDAVF) is a rare condition in which an abnormal connection exists between the arteries and veins surrounding the spinal cord [1] This is often initially asymptomatic but can begin to cause symptoms such as lower extremity weakness or sensory deficits, back or leg pain, and bowel or bladder dysfunction. We present a case of a 61-year-old Caucasian patient with spinal degenerative disease and an unrecognized SDAFV who had sudden onset of cauda equina syndrome following an interlaminar, fluoroscopy-guided epidural steroid injection He presented with low back pain, inability to walk, paresthesias of his bilateral lower extremities, bowel and bladder incontinence, and saddle anesthesia. He denied any history of intravenous drug abuse, fever, chills, or other infectious symptoms. The case was complicated only by urinary retention, which resolved at eight months

Discussion

Conclusions

Disclosures