Rare Case of Ischaemic Stroke Following Cervical Transforaminal Injection

Abstract

We report a case of brainstem infarction following a C5–C6 cervical transforaminal injection, a rare and serious neurological complication of this procedure. Cervical transforaminal steroid injection is a common therapy for patients with persistent cervical radiculopathy not relieved by conservative treatment, and is effective in 65–70% of cases. Unfortunately, this procedure may lead to serious complications such as neurological damage. These complications are rare but potentially fatal, as reported in our case. Complications could be due to three mechanisms: the technique itself, the cervical vascular anatomy and the properties of the product (corticoids). The neurological complications can be diagnosed through brain MRI. This case report focuses on the importance of a risk/benefit evaluation when performing this medical procedure. LEARNING POINTS Physicians should be better informed about severe complications following cervical transforaminal epidural steroid injections and their strict indications. Severe adverse events are rare but they can be disastrous. Non-particulate corticosteroid should be used.

Suspected ischaemic myelopathy following lumbosacral epidural steroid injection in a dog

“…7,8 Reports of spinal cord ischaemia, paralysis, permanent blindness and death after ESI have raised concerns about the potential embolisation of particulate corticosteroids. [8][9][10][11][12] To the authors' knowledge, development of ischaemic myelopathy following ESI has not been previously described in dogs. It is hoped that this case report will raise awareness regarding this unusual complication that can occur following a routine procedure.…”

“…There have been numerous reports in the human literature of spinal cord infarction following ESI. 11,[13][14][15]20 These cases of spinal cord infarction have been theorised to occur either due to direct vascular injury or embolisation from particulate corticosteroids, with an emphasis on the latter. [6][7][8][9]13,15,16 As such, particulate steroid embolisation was highly suspected in cases where epidural bleeding, epidural abscess or operator error were not identified.…”

The safety and efficiency of performing cervical transforaminal epidural steroid injections under fluoroscopic control on an ambulatory/outpatient basis

“…Although significant adverse reactions/complications are uncommon, there is a body of evidence limited to individual case reports describing an array of severe neurological [10]. Our literature search identified one further more recent case of death following CTFESI [11]. Furthermore, a survey of 1340 pain specialists with 287 responders reported 30 cases of infarction of the brain and/or spine and 13 cases of death in their cumulative experience of performing CTFESI [12].…”

“…Furthermore, a survey of 1340 pain specialists with 287 responders reported 30 cases of infarction of the brain and/or spine and 13 cases of death in their cumulative experience of performing CTFESI [12]. Whilst a minority of the published complications have been attributed to direct intra-medullary injection, vertebral artery dissection and high spinal anaesthesia, many of the complications have been attributed to intra-arterial injection [10][11][12][13].…”

“…Given the close proximity of the exiting cervical nerve root to the adjacent vertebral and radicular arteries, concerns regarding procedure safety are justifiable. Whilst complications are infrequent, growing numbers of reports have described severe neurological complications following CTFESI including spinal cord, brainstem and cerebellar infarcts, and even death [10][11][12][13]. Whilst the theoretical risk associated with inadvertent arterial cannulation and intra-arterial steroid injection is certainly greater with particulate steroids, much of the literature evidencing the potential complications of CTFESI has focused on the choice of steroid as the cause rather than addressed the question of operator technique [3][4][5][14][15][16].…”