Possible causes for neurologic complications after a caudal epidural injection include an inadvertent intrathecal injection, epidural abscess, and epidural hematoma [ 4 ]. First, in this case, inadvertent intrathecal injection seems unlikely for the following reasons; MRI showed a normal anatomy of the dural sac, with its extension limited to the first sacral vertebra; the needle was advanced inwards for only 2. Furthermore, intrathecal injections have bilateral effects, whereas the patient's symptoms mainly persisted unilaterally.
In such cases of unilateral motor weakness and numbness, the possible presence of a midline epidural septum may be considered [ 5 ]. However, the initial bilateral numbness that appeared 10 minutes post-procedure ruled out this possibility. Second, although rare, an epidural abscess is also capable of causing paraplegia or paralysis with vertebral pain, fever, and motor and sensory deficits.
Nonetheless, it is reported in the literature that an average of 5 days are needed for the symptoms to manifest [ 4 ], which does not align with the details of our case. Finally, epidural hematoma, a rare but serious complication, can cause neurologic deficits that can remain permanent despite an emergency laminectomy [ 4 ]. Rapid diagnosis and treatment are crucial to counter its rapid progress. In the initial hours of our case, when the symptoms failed to improve, ruling out an epidural hematoma was crucial, providing the rationale for an emergency MRI study.
Both the T1- Fig. The MRI readings strongly suggested that the lesion was trapped epidural air rather than a hematoma. In the presence of epidural hematoma, the initial MRI findings during the first 12 hours are characterized by an almost equivalent signal in the T1-weighted MRI and a slightly high signal in the T2-weighted MRI [ 6 ].
However, the patient's 4-hour post-procedure MRI findings showed a low signal lesion in both the T1- and T2-weigted images. Hence, the possibility of a hematoma was ruled out. With these possible causes ruled out, it was highly suspected that the patient's neurological symptoms were due to an air bubble trapped near the right S1 nerve root. Although no clear signs of direct nerve compression were seen, consulting doctors from orthopedics and radiology all agreed that an air bubble, as a space occupying lesion, was highly likely to account for the symptoms.
This conclusion was based on the fact that previously nonexistent symptoms of right ankle plantar flexion impairment and S1 dermatome numbness appeared after the procedure, with manifestations similar to an S1 radiculopathy. Epidural air can spread along the nerves of the paravertebral space, and, depending on its location, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia can occur [ 7 , 8 ].
Kennedy et al. Computed tomography CT showed the epidural space from L1 to L4 filled with air, with the thecal sac of the L2 and L3 levels severely compressed. After a spinal needle was introduced into the epidural space, removing 15 ml of air, the patient promptly recovered. Miguel et al. The CT showed compression due to air trapping on the spinal nerve roots of the corresponding symptomatic dermatomes.
There have also been reported cases of subcutaneous emphysema developing at the supraclavicular region after epidural anesthesia, commonly due to injection of more than 20 ml of air after multiple failures or difficult attempts to identify the epidural space [ 10 ]. Cuerden et al. All patients recovered within 48 hours.
The authors concluded that air caught in the epidural space is absorbed within 24 to 48 hours, resulting in spontaneous resolution of the symptoms. This also was the case for our patient because her symptoms subsided within 48 hours. Unlike the above reports, the volume of air used in our patient was minimal. However, it is highly likely that the air trapped in the right S1 nerve root was responsible for the unilateral motor weakness and the numbness of the S1 dermatome.
Waldman [ 2 ] suggested the use of 1 ml of air for the air-acceptance test. Similarly, in our case, 1 ml of air was injected to find resistance, and then the needle was advanced 0. Thus, a total of 2 ml of air was used. With the aid of the Rapidia 2. Stevens et al. They reported that air bubbles collect near the outlet space for the exiting nerve roots.
Therefore, while a large amount of air injection may cause radiculopathy, even the smallest amount of air may show up on an MRI as a herniated disc [ 13 ]. Because epidural gas is absorbed spontaneously, the first line of treatment in patients with neurologic symptoms must be conservative, using nonsteroid anti-inflammatory drugs and muscle relaxants, along with close observation.
Gas aspiration under fluoroscopic guidance can be considered; however, in our case, the gas volume was too small for the patient to undergo such a procedure. Surgery should be reserved for chronic encapsulated lesions not responding to conservative therapy [ 14 ]. To prevent complications from epidural air, only a minimal amount of air should be injected.
Furthermore, the use of ultrasound or fluoroscopic guidance with contrasts can be considered as alternatives to the air-acceptance test [ 15 ]. In conclusion, using even a minute amount of air during caudal epidural injection can cause air trapping around a nerve root and induce neurologic complications.
Hence, more precautions should be taken during such procedures. National Center for Biotechnology Information , U. Journal List Korean J Pain v. Korean J Pain. Published online Jul 1. Find articles by Mi Hyeon Lee. Find articles by Cheol Sig Han. Find articles by Sang Hoon Lee. Find articles by Jeong Hyun Lee. Find articles by Eun Mi Choi. Find articles by Young Ryong Choi. Find articles by Mi Hwa Chung. Author information Article notes Copyright and License information Disclaimer. Corresponding author.
Received Mar 4; Accepted Apr 3. This article has been cited by other articles in PMC. Abstract Air injected into the epidural space may spread along the nerves of the paravertebral space. Keywords: caudal epidural block, complications, epidural air, epidural injection. CASE REPORT The patient, a year-old female with a weight of 48 kg, height of cm, and no significant medical history or underlying condition was admitted to the orthopedic ward for low back pain. Open in a separate window.
References 1. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician. Waldman SD. Pain management. Of the patients who had increased pain, one also had pain at the injection site, one had chest pain, and one had a headache. One patient had both numbness and weakness, and one patient had both pain at the injection site and fever. As discussed above, all symptoms resolved spontaneously.
Our retrospective review of 4, ESIs showed no major complications, and a very low rate of minor complications 2. These finding are in agreement with similar studies, which showed complication rates ranging from 0. The most common minor complication reported was increased pain following the injection.
We suspect this to be due to local effects of the needle or the injectate, and this finding is not surprising as this population is already suffering from high pain levels. In our practice, most cases report this concern prior to the expected onset of corticosteroid effect, and no additional treatment besides use of analgesics, was required. However, these results suggest that more attention could be given to post-procedure analgesia. We have no clear explanation for the difference in complications between IL and TF injections 6.
Differences in corticosteroids are assumed not to play a role, as only one steroid, triamcinolone, was used in all injections. Fortunately, the rate of complications was found to be low for both procedures, and we could not determine any clear difference in the type of complications encountered between the two anatomical approaches. Possible explanations may include patient selection; we perform IL injections more commonly for patients with central stenosis or diffuse symptoms.
The single spinal headache complication was not a surprising finding, and fortunately was self-limited. Dural puncture is a complication of concern in any epidural injection . Spinal headaches tend to be self-limiting, but may require treatment with an epidural blood patch . Dural puncture is also concerning for injection of anesthetic into the subdural space, which may result in subdural neural blockade.
Symptoms of this complication include motor and sensory loss, with a delayed onset of 5—30 minutes . Dural puncture can be recognized promptly by detection of cerebrospinal fluid flow as was the case in our patient or by fluoroscopy, if contrast medium is injected before any other agents. Therefore, interventionalists must be able to distinguish between epidural and subdural contrast flow patterns.
It is possible that inadvertent dural puncture occurred in the other patients who reported headache, and in other cases who remained completely asymptomatic, but this was unable to be determined by our review methods. Other significant potential side effects of corticosteroids include weight gain, fluid retention, hyperglycemia  , osteoporosis  , avascular necrosis of bone  , and pituitary-adrenal axis suppression .
These concerns were outside the scope of our study, but remain important considerations in the discussion of injection risks. Local anesthetics are injected with corticosteroids in ESIs, and thus complications may take the form of reactions to local anesthetic. A prospective review of lidocaine for spinal anesthesia in 10, patients found that 3. Besides headache, none of these effects were noted in our study, probably because they were epidural and not spinal blocks, and the symptoms tend to have more acute onset immediately after the procedure.
As in any imaging procedure using X-rays, radiation exposure presents a potential problem, with the risk of complications increasing with repeated exposure [28,29]. Another rare but potentially serious complication is paraplegia, possibly resulting from intraarterial injection  or injection directly into the spinal cord . Such complications demonstrate the necessity of recognizing abnormal flow patterns during test injection of contrast media. Though this study takes advantage of a large sample size over a number of years, it is not without limitations.
In any retrospective study, confounding variables are more difficult to control for than in prospective studies. Ours is a single-center study, and as such involves a more limited number of interventionalists and less variation in treatment methodologies than multicenter studies. The demographics of the patients involved in this study are limited to those who seek care at an urban, academic center. During the time period we examined, there was no systematic means of contacting patients post-procedure, although the vast majority of patients were followed at our institution for ongoing care.
Therefore, some patients who may have had complaints if contacted may have been missed. Finally, we cannot predict how many patients may have been lost in follow-up to sites outside of our institution. Though ours is the only major trauma center in the greater metropolitan area, and the majority of our patients reside within this area, there are multiple other major medical centers, and it is impossible to tell whether some patients would present to another institution.
This retrospective chart review of 4, fluoroscopically guided ESIs performed in 1, patients revealed an overall complication rate of 2. There were no major complications, and all minor complications resolved without permanent morbidity.
These results suggest that ESIs are a safe and well-tolerated intervention for cervical or lumbar pain and radiculopathy. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil ; 81 8 : — Google Scholar. Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society clinical practice guideline. Spine Phila Pa ; 34 10 : — Ackerman WE 3rd Ahmad M.
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Six weeks is often quoted as a reasonable timeframe to try these more conservative approaches before consideration of an ESI. However, in cases of severe or debilitating pain, or neurological signs or symptoms, an earlier ESI is reasonable and often very helpful. During your initial consultation, your provider will review your medical history and imaging, and perform a physical examination.
If we believe an ESI is the right treatment approach for you, we will discuss the procedure in detail so that you understand what is involved before moving forward. It is important to note that while the ESI can provide pain relief, rehabilitation with physical therapy will still be necessary in most cases. You should be able to be more successful with your rehabilitation efforts while taking advantage of the pain relief provided by the ESI. Clinical research has shown that ESIs can, in many cases, provide significant relief of pain on the order of weeks to months, or possibly more long-term.
They can not only reduce the chances of needing surgery, ESIs also provide relief for enough time to allow you to progress through a rehabilitation program and improve your level of function. If the ESI provides some duration of pain relief but symptoms return, a second injection may be considered in the following cases:.
The decision to proceed with a second or third injection is made in consultation with your spine care provider. It is usual to wait two weeks or more between injections. ESIs have been used since the s for the treatment of back pain. Since that time, technology has improved, and currently the accepted method is to perform a targeted injection under fluoroscopic X-ray guidance.
Before undergoing an ESI, you must complete the pre-injection process, which involves:. After this process has been completed, you will have your ESI scheduled. There are two types of ESIs used:. It can take between three days and two weeks for the steroid to reach maximum effect.
This syndrome causes loss of bowel and bladder control and must be treated immediately to prevent paralysis of the lower body. Sometimes, low blood pressure and decreased heart rate may occur after an epidural steroid injection. Larger particles in particulate steroids may lump together and block blood vessels, causing reduced blood supply to the spinal cord.
Risks and complications are typically higher in epidural steroid injections administered above the L3 level. Serious symptoms following an epidural steroid injection that require immediate medical attention include:. See Osteomyelitis Symptoms. See Cauda Equina Syndrome Symptoms. It is important to call the doctor immediately if these symptoms occur.
Additionally, any discomfort or abnormal feeling must be discussed with the doctor. Epidural Steroid Block Video. Injections for Neck and Back Pain Relief. Sciatica Treatment. Epidural Steroid Injections. You are here Treatment Injections. By Richard Staehler, MD. Peer Reviewed. Epidural Steroid Injection Video. Safety of Epidural Corticosteroid Injections. Drugs R D. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain.
Pain Physician. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord. Published May Cham, Switzerland: Springer; Chang, Douglas, Zlomislic, Vinko.
J Pain Symptom Manage ; steroid injection: Leg weakness after epidural steroid injection case report. Pharmacotherapy ; 25 8 : E-8. J Neurosurg ; 93 suppl 1 : 1 - 7. Epidurography and therapeutic epidural injections: nerve root block C7 due. Pain Physician ; 8 3 : - Paralysis after transforaminal chronic aseptic lumbar epidural abscess. Anaesth Intensive Care ; 31 Implications for its use in. Spine ; 26 suppl 24 injections by expert interventionalist in improvement in pain as well. What are side effects of S31 - 7. Am J Phys Med Rehabil ; 80 6 : - of fluoroscopically guided caudal epidural. Anesth Analg ; 4 : syndrome after diagnostic blockade of.Please call your doctor if you experience any of the following after your injection: Redness or swelling at the injection site. Fever of F ( C) or higher. New or worsening weakness or. Injection of local anesthetics or steroids into the epidural felt numbness in both legs and muscle weakness in the right lower leg. What can you expect after a lumbar epidural steroid injection? If your injection had local anesthetic and a steroid, your legs may feel heavy or numb right.