Skip to main content
SpringerLink
Log in

Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature

  • Interventional
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Background

Selective steroid injections of the lumbar spine carry a risk of paraplegia of sudden onset. Seven cases have been reported in the English literature since 2002.

Materials and methods

Five new cases have been analyzed, all coming from Paris area centers. Injections were performed between 2003 and 2008. The following items were searched for: location of a previous lumbar spine surgery if any, symptoms indicating the procedure, route of injection, imaging technique used for needle guidance, injection of a contrast medium, type of steroid, other drugs injected if any, paraplegia level, post-procedure MR findings. The current and reported cases were compared.

Results

MR findings were consistent with spinal cord ischemia of arterial origin. The high rate of patients who had been operated on in these cases does not correspond to that of patients undergoing injections. The presence of epidural scar might increase the risk. The foraminal route was the only one involved in nonoperated patients. Foraminal, interlaminar, or juxta-zygoapophyseal routes were used in operated-on patients.

Conclusion

The high rate of French cases when compared to the literature might arise from the almost exclusive use of prednisolone acetate, a molecule with a high tendency to coalesce in macro-aggregates, putting the spinal cord at risk of arterial supply embolization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Houten JK, Errico TJ (2002) Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2:70–75

    Article  PubMed  Google Scholar 

  2. Huntoon MA, Martin DP (2004) Paralysis after transforaminal epidural injection and previous spinal surgery. Reg Anesth Pain Med 29:494–495

    PubMed  Google Scholar 

  3. Somayaji HS, Saifuddin A, Casey ATH, Briggs TWR (2005) Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection. Spine 30:E106–E108

    Article  CAS  PubMed  Google Scholar 

  4. Quintero N, Laffont I, Bouhmidi L, Rech C, Even Schneider A, Gavardin T, Dizien O (2006) Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review. Ann Readapt Med Phys 49:242–247

    CAS  PubMed  Google Scholar 

  5. Glaser SE, Falco F (2005) Paraplegia following a thoracolumbar transforaminal epidural steroid injection. Pain Physician 8:309–314

    PubMed  Google Scholar 

  6. Lenoir T, Deloin X, Dauzac C, Rillardon L, Guigui P (2008) Paraplegia after interlaminar epidural steroid injection: a case report. Rev Chir Orthop 94:697–701

    CAS  PubMed  Google Scholar 

  7. Tajima T, Furukawa K, Kuramochi E (1980) Selective lumbosacral radiculography and block. Spine 5:68–77

    Article  CAS  PubMed  Google Scholar 

  8. Martin DP, Huntoon MA (2005) Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection. Spine 30:1558

    Article  PubMed  Google Scholar 

  9. Yuh WT, Marsh EE, Wang AK, Russell JW, Koci TM, Ryals TJ (1992) MR imaging of spinal cord and vertebral body infarction. Am J Neuroradiol 13:145–154

    CAS  PubMed  Google Scholar 

  10. Thron AK (1988) Vascular anatomy of the spinal cord. Neuroradiological investigations and clinical syndromes. Springer-Verlag, Wien, pp 8–12

    Google Scholar 

  11. Mawad M, Rivera V, Crawford S, Ramirez A, Breitbach W (1990) Spinal cord ischemia after resection of thoracoabdominal aneurysms: MR findings in 24 patients. AJNR 11:987–991

    CAS  PubMed  Google Scholar 

  12. Mc Lain RF, Fry M, Hecht ST (1997) Transient paralysis associated with epidural steroid injection. J Spinal Disord 10:441–444

    Article  CAS  Google Scholar 

  13. Osborn AG (1994) Diagnostic neuroradiology. Mosby, St. Louis

    Google Scholar 

  14. Toro G, Roman GC, Navarro-Roman L, Cantillo J, Serrano B, Vergara I (1994) Natural history of spinal cord infarction caused by nucleus pulposus embolism. Spine 19:360–366

    Article  CAS  PubMed  Google Scholar 

  15. Djindjian R, Hurth M, Houdart R (1970) Angiography of the spinal cord. Masson, Paris, pp 1–26

    Google Scholar 

  16. Bert S, Iyriboz AT, Barret F, Zouaoui A, Chiras J (1995) An angiographic study of the spinal vascularization at the thoracic lumbar level. J Neuroradiol 22:12–19

    CAS  PubMed  Google Scholar 

  17. Lo D, Vallée JN, Spelle L, Cormier E, Saillant G, Rancurel G, Chiras J (2002) Unusual origin of the artery of Adamkiewicz from the fourth lumbar artery. Neuroradiology 44:153–157

    Article  CAS  PubMed  Google Scholar 

  18. Desproges-Gotteron R (1955) Contribution à l’étude de la sciatique paralysante. Thèse Médecine N°342, Paris

  19. de Sèze S, Guillaume J, Desproges-Gotteron R, Jurmand SH, Maitre M (1957) Sciatique paralysante (Etude clinique, pathogénique, thérapeutique d’après 100 observations). Sem Hôp Paris 28:548–572

    Google Scholar 

  20. Biglioli P, Roberto M, Cannata A, Parolari A, Fumero A, Grillo F, Maggioni M, Coggi G, Spirito R (2004) Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries. J Thorac Cardiovasc Surg 127:1188–1192

    Article  PubMed  Google Scholar 

  21. Fautrel B, Rozenberg S, Koeger AC, Willer JC, Bourgeois P (1998) L5-S1 disc origin for a pyramidal syndrome? Lancet 352:1679

    Article  CAS  PubMed  Google Scholar 

  22. Balblanc JC, Pretot C, Ziegler F (1998) Vascular complication involving the conus medullaris or cauda equina after vertebral manipulation for an L4-5 disk herniation. Rev Rhum 65:279–282

    CAS  Google Scholar 

  23. Tiso RL, Cutler T, Catania JA, Whalen K (2004) Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J 4:468–474

    Article  PubMed  Google Scholar 

  24. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C (1998) Cervical epidural steroid injection with intrinsic spinal cord damage: two case reports. Spine 23:2137–2140

    Article  CAS  PubMed  Google Scholar 

  25. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL (2001) A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain 91:397–399

    Article  CAS  PubMed  Google Scholar 

  26. Rozin L, Rozin R, Koehler SA, Abdulrezzak S, Ladham S, Mamdouha B, Dominick J, Wecht CH (2003) Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J For Med Pathol 24:351–355

    Article  Google Scholar 

  27. Ludwig MA, Burns SP (2005) Spinal cord infarction following cervical transforaminal epidural injection. Spine 30:266–268

    Article  Google Scholar 

  28. Suresh S, Berman J, Connel DA (2007) Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block. Skeletal Radiol 36:449–452

    Article  CAS  PubMed  Google Scholar 

  29. Okabadejo GO, Talcott MD, Schmidt RE, Sharma A, Patel A, Mackey RB, Guarino AH, Moran CJ, Riew KD (2008) Perils of intravascular methylprednisolone injection into the vertebral artery: an animal study. J Bone Joint Surg (Am) 90:1932–1938

    Article  Google Scholar 

  30. Roques CF, Condouret J, Soleihavoup JP, Croute F (1987) Les corticoïdes pour infiltrations intra-articulaires : éléments de choix (puissance, microcristaux, excipient). Rhumatologie 39:187–194

    Google Scholar 

  31. Francis AF, Chang EL, Haik BG (1996) Particle size and drug interactions of injectable corticosteroids used in ophthalmic practice. Ophthalmology 103:1884–1888

    CAS  PubMed  Google Scholar 

  32. Ross JS, Modic MT, Masaryk TJ, Carter J, Marcus RE, Bohlman H (1989) Assessment of extradural degenerative disease with Gd-DTPA-enhanced MR imaging: correlation with surgical and pathologic findings. Am J Neuroradiol 10:1243–1249

    CAS  PubMed  Google Scholar 

  33. Van Goethem JWM, Parizel PM, Jinkins JR (2002) Review article: MRI of the portoperative lumbar spine. Neuroradiology 44:723–739

    Article  PubMed  Google Scholar 

  34. Berenstein A, Lasjaunias P (1992) Surgical neuroangiography. Springer-Verlag, Heidelberg, pp 113–118

    Google Scholar 

  35. Link SC, El-Khoury GY, Guilford WB (1998) Percutaneous epidural and nerve root block and percutaneous lumbar sympatholysis. Radiol Clin N Am 36:509–521

    Article  CAS  PubMed  Google Scholar 

  36. Kelekis AD, Somun T, Yilmaz H, Bize P, Brountzos EN, Lovblad K, Ruefenacht D, Martin JB (2005) Interventional spine procedures. Eur J Radiol 55:362–383

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Musculoskeletal Radiology Department, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France

    Marc Wybier, David Petrover & Jean-Denis Laredo

  2. Radiology Department, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Clichy, France

    Sandrine Gaudart

  3. Neuroradiology Department, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France

    Emmanuel Houdart

  4. Service de Radiologie Ostéo-articulaire, Hôpital Lariboisière, 2 rue Ambroise Paré, 75010, Paris, France

    Marc Wybier

Authors
  1. Marc Wybier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sandrine Gaudart
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David Petrover
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emmanuel Houdart
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jean-Denis Laredo
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marc Wybier.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wybier, M., Gaudart, S., Petrover, D. et al. Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol 20, 181–189 (2010). https://doi.org/10.1007/s00330-009-1539-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-009-1539-7

Keywords

Search

Navigation