Spontaneous Resolution of Presumed Acute Epidural Hematoma Formation After Lumbar Epidural Steroid Injection

Abstract

Epidural steroid injections are interventional pain procedures often used to treat lumbar radicular pain. The most serious complication of this procedure is the formation of a spinal epidural hematoma, which can result in profound permanent neurologic deficits if left untreated. A 76-year-old woman with mild lumbar spinal stenosis (L4-L5, L5-S1) and lumbar dextroscoliosis, previously on 81mg of aspirin daily (discontinued at 14 days prior to procedure) and not on anticoagulation therapy, underwent a lumbar epidural steroid injection (T12-L1). Post-procedurally, she developed bilateral leg paralysis. A magnetic resonance imaging (MRI) study revealed a fluid collection concerning for hematoma. Neurosurgery was consulted, but at the time of evaluation, she had near resolution of her presenting symptoms and the decision was made to monitor her for 48 hours. Three months after discharge, MRI revealed no persistent symptoms or radiographic evidence of sequelae from epidural hematoma. The frequency of spinal epidural hematomas after epidural steroid injections is unknown. This patient did not have traditional risk factors of severe spinal stenosis or the use of anticoagulant or antiplatelet agents. A radiographic fluid collection was seen, which may represent blood or persistent injectate. A formal surgical diagnosis was not obtained, as her symptoms spontaneously improved without further need for intervention. We report the first case of presumed persistent injectate compression of the lumbar spinal cord, resulting in bilateral lower extremity weakness in a patient with dextroscoliosis, mimicking spinal epidural hematoma with spontaneous resolution without intervention. Key words: Epidural steroid injection, spinal epidural hematoma, dextroscoliosis, lumbar radiculopathy, spinal stenosis, lower extremity paralysis