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23rd Annual Meeting February 7-10, 2007 New Orleans, LA |
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© 2006 American Academy of Pain Medicine |
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Thursday, February 8, 2007
115
Predominantly Neurological Deficits after Epidural Steroid Injection: Time Course, Differential Diagnoses, Management and Prognosis Suggested by Review of Case Reports
Objectives: To elucidate predominantly neurological deficits after ESIs and suggest a diagnostic algorithm to guide clinicians towards appropriate immediate management.
Methods: An Internet search was conducted for case studies of neurological deficits after ESI and cross-referenced for mechanism of injury, diagnosis, temporal onset, management, and outcomes.
Results: Thirty-three cases from 1990-2006 were reviewed, with 19 permanent deficits and 14 reversible. Ten infarctions and 9 not-infarctions resulted in permanent deficits, while reversible deficits were due to 1 infarction and 13 not-infarctions (p<=.008). Five of 6 deficits associated to mass occupying lesions (MOL) had complete recovery, while only 1 of 11 infarctions recovered (p<=.005). Onset of 14 of 19 permanent deficits was during injection and “just-after-injection.” Onset of reversible deficits was distributed between 0-30 minutes, 30 minutes to 3 hours, and after 24 hours (p<=.036). Infarctions presented just-after-injection in 9 of 11 cases. Mass-occupying lesions (MOL) did not show a significant time of onset. Initial imaging was abnormal in 13 of 18 cases.
Conclusions: Differential diagnosis for neurological deficits after ESIs includes infarction, epidural and subdural hematoma, aseptic abscess, vascular occlusion, injection and dissection of arteries, neural trauma, chemotoxicity, and inadvertent subdural and intrathecal injection. Temporal onset of deficits aids in differential diagnosis. Infarctions significantly occur just after injection and are permanent. Presenting with similar timeframe but resolving within 8 hours, subdural and intrathecal injections are distinguished by characteristic cardiovascular changes. MOL presented thirty minutes to 8 days after ESI. Decompression within 8 hours affords best outcome. Respiratory instability and death may follow quadriplegia and loss of consciousness. Certain rare neurological deficits can complicate ESI: Physicians should have urgent access to neuro-imaging, neuro-surgical and cardiovascular support, and airway management.
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Funding: None
Nothing to disclose.