Enlargement of a chronic aseptic lumbar epidural abscess by intraspinal injections - a rare cause of progressive paraparesis

Abstract

The frequent use of invasive procedures at the spinal cord such as epidural injections has led to an increased incidence of iatrogenic abscesses. We report the case of a patient who suffered from low back pain. During epidural lumbar injections of steroids the patient developed severe radicular symptoms, resulting in severe paraparesis. We demonstrate the rare cause of this progressive deterioration, being a combination of a preexisting chronic aseptic epidural abscess and an iatrogenic enlargement by repeated epidural injections. MR-Scans demonstrated a mass lesion at the L4/5 vertebral level, which was surgically removed. Histological evaluation revealed the presence of a chronic aseptic spinal epidural abscess with acute bleedings. Histology and MR-Data disclosed multiple deposits of the applied drug within the abscess and in the surrounding paravertebral soft tissue. The authors prove that the cause of the neurological deterioration was due to epidural injections into a preexisting lumbar chronic aseptic epidural abscess. Harmful and unpleasant complications may occur following epidural injections. Though we present a very rare cause of such complications, a careful monitoring of the neurological status of the patient is necessary as well as the early application of MR imaging in the case of deterioration.

Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the Case Report Literature

“…Including our report, an ESR, CRP or both were elevated in nine of 10 patients in which these tests were obtained [2,6,10,12,14,15,21,27]. The CRP was not elevated in an asplenic diabetic patient diagnosed with an epidural abscess [16]. The median value for the ESR and CRP was 95 mm/h (75% interquartile range 100 mm/h) and 8 mg/dL (75% interquartile range 17 mg/L), respectively.…”

“…Including our patient, the median time to symptom onset in patients who had an infectious complication after a spinal injection was 7 days (75% interquartile range 21 days). In this group of 27 patients, the predominant presenting symptoms included worsening spinal or extremity pain [2,10–12,14,15,17,19,21,22,24–27], worsening pain in addition to neurological deficits [5,6,8,9,13,18,20,23] including our patient, and neurological deficits only [3,16]. These three groups of symptoms comprised 25 of 27 (92%) patients who had an infectious complication.…”

“…In the single report of discitis after a caudal epidural injection, the patient was a 73‐year‐old woman with a history of chronic “mechanical” low back pain, neurogenic claudication, and diabetes mellitus [2]. Including our patient and the previous case report of discitis, 20 infectious complications following interlaminar or caudal epidural corticosteroid injections were identified of which 15 received lumbar epidural injections [3–6,9–12,14–20] and two received caudal injections [2,12]. Considering these 17 patients, the infectious complications included epidural abscesses [5,9,12,14–18], epidural abscesses with meningitis [3,6,19], intradural abscesses [10,20], meningitis [4,11], and discitis.…”

“…Including our patient and the previous case report of discitis, 20 infectious complications following interlaminar or caudal epidural corticosteroid injections were identified of which 15 received lumbar epidural injections [3–6,9–12,14–20] and two received caudal injections [2,12]. Considering these 17 patients, the infectious complications included epidural abscesses [5,9,12,14–18], epidural abscesses with meningitis [3,6,19], intradural abscesses [10,20], meningitis [4,11], and discitis. Including our case report, 11 patients had a history of diseases or were taking medication that impaired immune function, including diabetes [2,5,6,12,15,16], metastatic cancer [3,9], neutropenia [19], oral steroid use [18], and previous infections [6].…”

“…Compared with patients who had infectious complications after facet joint, selective nerve root, transforaminal epidural or sacroiliac joint injections, patients who had an infectious complication after an interlaminar or caudal epidural injection were more likely to be immunocompromised ( P = 0.02). All patients, regardless of injection type, were administered a depot corticosteroid [2–27].…”