Epidural Hematoma Causing Paraplegia After a Fluoroscopically Guided Cervical Nerve-Root Injection

Abstract

Extraforaminal cervical nerve-root blocks, administered under image guidance, are extremely useful for both the diagnosis and treatment of cervical radiculopathy. In terms of safety, Ma et al., in their analysis of fluoroscopically guided cervical nerve blocks, found no instances of paralysis in their 1036 patients after injection1. Although devastating neurological complications after cervical transforaminal nerve block are rare, there have been anecdotal case reports of spinal cord infarction2-4, injection into surrounding vascular structures5,6, epidural abscess7, and cerebellar and/or brain-stem herniation and infarction8,9. An expanding epidural hematoma is a rare complication that can cause major neurological morbidity. Repeated injections, preexisting coagulopathy, and the use of anticoagulation or antiplatelet medications are known risk factors for the development of an epidural hematoma in the lumbar spine after an injection10-13. Injection-related epidural hematomas in the cervical spine have rarely been reported11,14. Consequently, the risk factors for the development of cervical epidural hematoma following transforaminal nerve-root injection are not clearly defined. We present the case of a patient with dense paralysis as a result of a slowly expanding cervical epidural hematoma that developed after a series of image-guided transforaminal cervical nerve-root injections. The only potential risk factor identified in this patient was the administration of multiple injections. Our patient was informed that data regarding this case would be submitted for publication. An otherwise healthy, thirty-eight-year-old woman was involved in a motor-vehicle accident that resulted in a right upper-extremity radiculopathy. She was initially evaluated and treated by an orthopaedic surgeon who recommended physical therapy and cervical epidural injections. After a short course of physical therapy, the patient underwent a series of three fluoroscopically guided right transforaminal epidural injections at the C7-T1 level. …