Abstract
Despite widespread use, the efficacy of epidural corticosteroid injections (ESI) for osteoarthritis-associated neck or radicular pain remains uncertain, so even rare serious complications enter into discussions about use. However, various factors impede investigation and publication of serious adverse events. To that end, we developed new magnetic resonance imaging (MRI) techniques for spinal cord white matter quantification and used the best available physiological tests to characterize a cervical spinal cord lesion caused by inadvertent intramedullary injection of Depo-Medrol. A 29-year-old woman with mild cervical osteoarthritis had 2years of headache and neck pain (concussion and whiplash) after 2 minor motor vehicle accidents. During C5–6 ESI, she developed new left-sided motor and sensory symptoms, and MRI demonstrated a new left dorsal spinal cord cavity. Mild left-sided motor and sensory symptoms have persisted for more than 2.5years, during which time we performed serial neurological examinations, standard electrodiagnostics, somatosensory evoked potentials, and transcranial measurement of corticospinal central motor conduction time (CMCT). We used 3-Tesla MRI with a 32-channel coil developed for high-resolution cervical spinal cord structural imaging, diffusion tensor imaging (DTI), and magnetization transfer (MT). T2∗-weighted signal and DTI and MT metrics showed delayed spread of the lesion across 4 vertebral levels rostrally, consistent with Wallerian degeneration within the ascending left dorsal columns. However, only CMCT metrics detected objective correlates of her left hemiparesis and bilateral hyperreflexia. DTI and MT metrics may better distinguish between post-traumatic demyelination and axonal degeneration than conventional MRI. These tests should be considered to better characterize similar spinal cord injuries.
Highlights
Two prospective [18,49] and a half-dozen retrospective studies find complications rare but relatively more frequent after cervical than lumbar epidural-steroidinjection (ESI) [47]
In addition to the experimental magnetic resonance imaging (MRI) technique developed for this case, she was evaluated with conventional diagnostic MRI and all available tests of integrity of peripheral and spinal motor and sensory pathways, conventional electromyography and nerve conduction study, upper- and lower-limb somatosensory evoked potentials, and measurement of upper- and lower-limb central motor conduction time (CMCT) using transcranial magnetic stimulation (TMS) of the motor cortex [16]
Stimulation applied over the posterior tibial nerves at the medial malleolus (11 mA, 200 μs; 2–5/s, minimum 500 superimposed stimuli) elicited symmetrical normal peripheral and central latencies and was interpreted as normal
Summary
Two prospective [18,49] and a half-dozen retrospective studies (vide infra) find complications rare but relatively more frequent after cervical than lumbar epidural-steroidinjection (ESI) [47]. Intramedullary injection can only complicate cervical or the rare thoracic injections because lumbar-ESI is performed below the conus medullaris. Usuallyminor complications of cervical-ESI include vomiting, flushing, hypotension, neck pain, dural puncture causing intracranial hypotension, and systemic corticosteroid effects [1,14]. Severe complications include subdural and intra-arterial injection, abscesses and granulomas, meningitis, osteomyelitis, plus nerve-root injury from needle, injectate, infection, or scarring. Spinal cord and brain injury are universally considered serious adverse events. Cervical spinal cord injury (SCI) is considered serious because of potential involvement of the arms as well as the legs (quadriparesis), cardiorespiratory compromise, and sudden death
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