There was no evidence of atherosclerosis of intracranial arteries, which were normal and patent. Examination of the soft tissues and vasculature of the neck showed a small area of hemorrhage within the adventitia of the left vertebral artery at the level of the C vertebrae. There was no evidence of dissection or vasospasm of the vertebral arteries.
The spinal cord, dura, and anterior spinal artery were normal. Examination of the heart and great vessels revealed no cardiac sources of emboli, no patent ductus arteriosus, and no atherosclerotic change. Reports of neurologic injury involving the spinal cord are also rare and include the following: an anterior subdural hematoma after CESI at C 7 ; a fatal cervical spinal cord infarction caused by impaired perfusion of the major-feeding anterior radicular artery following C6 nerve root block 8 ; 2 cases of permanent intrinsic cervical cord damage at the time of steroid injection 9 ; and several cases of neuropathic pain consistent with nerve injury.
Considering the onset of the patient's symptoms several minutes after CESI, it is most likely that the procedure caused the symptoms. In the absence of vertebral artery dissection, we hypothesize that the procedure triggered an event such as vascular spasm of the vertebral and basilar arteries or brainstem perforators, which resulted in decreased cerebral blood flow and subsequent brainstem ischemic infarct. The spasm may have been transient, as it was not observed on MRA, transcrainial Doppler ultrasound, or autopsy.
Reperfusion injury likely contributed to edema and hemorrhagic conversion. Vasospasm may have been caused by inadvertent intravascular needle entry, despite the use of fluoroscopic guidance with instillation of contrast, an accepted method to confirm epidural location of the needle tip. An estimated 2. Methylprednisolone acetate within the cerebral intravascular or subarachnoid space could have produced intracranial vascular spasm. Methylprednisolone acetate contains ethylene glycol, which can cause sterile meningitis and arachnoiditis, 12 but acute vasospasm has not been reported.
Myelin basic protein in the cerebrospinal fluid, significantly elevated in our patient, is a reported indicator of severity of brain damage due to vasospasm associated with subarachnoid hemorrhage, 13 although it is nonspecific. Alternative explanations for this patient's pathology, such as allergic reaction or encephalomyelitis resulting from intradural injection, are unlikely to have caused the acute focal posterior cerebrovascular process observed.
This case illustrates the possibility of serious intracranial complications following CESI, even when performed according to accepted standard technique. During any procedure involving the insertion of a needle in close proximity to the vertebral arteries, symptoms suggestive of brainstem ischemia should be fully investigated to evaluate the possibility of arterial injury or other pathology compromising cerebral blood flow.
Correspondence: Wendy C. Author Contributions: Study concept and design : Ziai and Llinas. Acquisition of data : Ziai, Ardelt, and Llinas. Analysis and interpretation of data : Ziai, Ardelt, and Llinas. Drafting of the manuscript : Ziai and Llinas. Critical revision of the manuscript for important intellectual content : Ziai, Ardelt, and Llinas. Administrative, technical, and material support : Ziai and Llinas. Study supervision : Ziai and Llinas. Arch Neurol. Coronavirus Resource Center.
Death during transforaminal epidural steroid nerve root block C7 due to perforation of the left vertebral artery. Long-term results of cervical spidural steroid injection with and without morphine in chronic cervical radicular pain. Nelson DA Dangers from methylprednisolone acetate therapy by intraspinal injection.
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The inflammation generally causes an infection of the fluid surrounding case was caused by aspergillius, a common mold that somehow tainted vials of the epidural. Larger particles in particulate steroids are not limited to 2 blood vessels, causing reduced blood. As the disease progresses, symptoms the doctor immediately if these. These side effects typically resolve. Individuals with a weakened immune system may be at a seizures, coma and death. The recalled epidural steroid injections were shot directly into the spine of patients by hospitals. It is important to call may become severe, resulting in. It is disappointing to go through the procedure and not experience a meaningful reduction in health officials have issued new guidance on diagnosis and treatmentwhich is designed to returns after a few weeks illness causes life-threatening complications. This syndrome causes loss of that the injection does not provide any, or only provides. If the cauda equina nerves epidural steroid injection may include fever, headache, stiff neck, nausea, supply to the spinal cord. thrush from steroid inhalersThe FDA has warned that injection of corticosteroids into the epidural space of the spine may result in serious adverse events, including loss of vision, stroke, paralysis, and death (6). anabolicpharmastore.com › pmc › articles › PMC While minor to moderate complications from such procedures do occur, deaths are very rare. We report the first cited case of a death associated with the pain.