Objective:

Describe a rare complication of cervical transforaminal epidural steroid injection (TFESI).

Background:

TEFSI is a commonly used procedure to treat cervical radicular pain. There are increasing concerns regarding the safety of particulate steroids due to risk of spinal cord infarction and quadriplegia.

Design/Methods:

N/A

Results:

A 36-year-old female with left-sided cervical radiculopathy due to C5-C6 disc osteophyte presented with acute quadriplegia (0/5 strength) and sensory loss (to light touch and pain approximately below C6), immediately following an elective C5-6 epidural bupivacaine injection. MRI revealed T2 hyperintense signal from C1/2 to T4 concerning for transverse myelitis and diffusion-weighted imaging changes concerning for an acute anterior spinal artery (ASA) stroke. Neurosurgery reviewed the MRI and did not think there was an indication for spinal angiography. She received five days of intravenous methylprednisolone and there was no clinical improvement. Rapid onset of symptoms suggested a periprocedural complication, likely attributable to the particulate steroid methylprednisolone. Her course was complicated by an acute deep vein thrombosis, requiring apixaban, and urinary retention requiring catheterization. Intermittent bradycardia was also noted, which improved without treatment, likely due to the cord lesion. There was no improvement on strength exam at time of discharge to acute rehab.

Conclusions:

This case highlights the risks associated with particulate steroid use in TFESI and underscores the importance of evaluating the risks versus benefits of corticosteroid use in cervical epidural steroid injections. The rapid onset of symptoms following the procedure suggests a periprocedural complication likely related to the particulate steroid used. The U.S. FDA has issued warnings regarding corticosteroid use in epidural injections, citing serious neurologic events. Non-particulate steroids like dexamethasone are considered safer alternatives. Adherence to guidelines recommending non-particulate steroids, along with further research, is essential to improve patient safety and reduce the risk of catastrophic outcomes in cervical ESI procedures.