Direct Spinal Cord Injury and Pneumocephalus: 
Epidural Steroid Injection Complications
Mitchell Foster MD, Ben Biewen MD, Aakash Shah MD, Evan Yates MD


Introduction

• Epidural steroid injection (ESI) is a commonly used pain management treatment for lumbar and cervical radiculopathy.

• Serious complications are rare, particularly with the utilization of fluoroscopy, however, there are reports detailing the potential for significant adverse events. 

• 52-year-old female PMH obesity and chronic back pain 2/2 DDD who presented to the ER with acute right-sided numbness and weakness with ataxia. 

• HPI: The day before hospital presentation the patient had a cervical ESI and PRP injection without fluoroscopy under MAC with propofol. When she awoke from anesthesia she experienced acute right-sided weakness and severe right-sided chest, abdomen, and extremity pain. She also developed a headache with nausea and emesis.

• Exam: Vital signs wnl. Mentation appropriate. Neuro exam included right-sided ptosis, miosis, extremity weakness (distal > proximal; upper > lower), and decreased sensation. Band-like dysesthesia around abdomen in T5-T9 distribution. RUE reflexes brisk. Consistent w/ central cord syndrome.

• Imaging: CT brain scattered foci of supratentorial subarachnoid pneumocephalus, scattered gas in posterior paraspinal soft tissue, a focus of gas along the central spinal canal at C5, and foci of gas along posterior epidural fat from T1-T2. MRI total spine showed signal abnormality in the right central cord from C4-T7 and C5 intramedullary air consistent with direct spinal cord injury with subsequent edema. 

• Treatment: Admitted to neuro service.  Started on 100% O2 with head of bed flat. IV methylprednisolone 1g daily x 5 days. Pain management service started pregabalin, acetaminophen, methocarbamol, venlafaxine, lidocaine patch, capsaicin cream, and prn ketorolac. 

• Outcome: Repeat MRI on hospital day 2 showed improvement of pneumocephalus, but persistent central cord edema. Despite PT and meds, her pain and neuro symptoms persisted. transferred to inpatient rehabilitation on hospital day 7. Continued functional improvement with 12 days of rehab. Follow up one month later with fixed neuro deficits unchanged from initial presentation (ptosis, right-sided weakness/sensory deficits, unrelenting neuropathic pain). She continues to undergo PT and pain management care.