Reversible Aggravation of Neurological Deficits after Transforaminal Epidural Steroid Injection in a Patient with Undiagnosed Spinal Dural Arteriovenous Fistula

Abstract

Here we present a case of a 77-year-old man who underwent an epidural steroid injection complicated by delayed monoplegia and urinary incontinence. An MRI showed T2 hyperintensity at the conus along with small serpentine vessels surrounding the spinal cord. An angiogram was performed which showed a spinal dural arteriovenous fistula (SDAVF) with prominent draining vein at the right L3 level. The patient underwent repeat laminectomy and disconnection of spinal dural fistula after failed endovascular repair. His symptoms slowly improved after the lumbar decompression and physical therapy. SDAVF remains a diagnostic challenge. Epidural injection is contraindicated in these patients due to venous hypertension resulting in possible conus ischemia. SDAVF must be considered in the differential diagnosis when unexpected neurological complications occur after epidural steroid injection.