23rd Annual Pain Medicine Meeting 2024

Unilateral Horner Syndrome Following Cervical Epidural Steroid Injection.

Mia A. Baringer, MD1, Quan Le, DO1, Daniel Katz, DO1

1Reading Hospital, Tower Health

44-year-old female with right arm radiculopathy underwent a right-biased paramedian epidural steroid injection (ESI) complicated in the post-procedural period by transient unilateral Horner Syndrome.

Background:

Occurs due to disruption of sympathetic nerves to the eye and face.
Incidence is 1 in 6,000, with 0.5% after neuraxial anesthesia.
Common symptoms include ptosis, miosis and anhidrosis.
Symptomology depends on the location of the lesion.
Severity depends on the degree of denervation.
Most often a clinical diagnosis (idiopathic causes are rare).

Discussion:

A PubMed search of “Horner’s Syndrome” and “Epidural Anesthesia” in humans yielded 39 reports, 24 in the parturient.
Anatomic / hormonal changes influence cephalic spread.
Long infusion durations cause thoracic accumulation.
Sympathetic blocks spread epidurally … could also in reverse?
The subdural space communicates intracranially!
Symptom onset / resolution should correlate with LA half-life.
Coordinate a diagnostic workup specific to the clinical scenario.

Differentials:

Ventral spread to spinal roots due to anatomic narrowing.
Caudal approach in setting of large LA volume resulted in cervical ganglia involvement.
Fluoroscopic confirmation ruled out subdural placement and traumatic needle insertion.
Unintentional migration of local topicalization.
CVA if specific focal neurological deficits were present.
Carotid injury / dissection unlikely given normal hemodynamics.

To date, there remains limited existing literature on episodes of Horner Syndrome following cervical epidural injections.

23rd Annual Pain Medicine Meeting 2024

UNILATERAL HORNER SYNDROME FOLLOWING A CERVICAL EPIDURAL STEROID INJECTION (ESI).

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