Cervical Interlaminar Steroid Injection and Stroke

Probably not related to particulate steroid embolization venous or arterial, or due to the needle stick itself or due to positioning. This complication was too late for all of these. However, steroids do raise the blood pressure, especially if already hypertensive, and can push the elderly over the edge. Another mechanism may be excessive patient cervical movement due to pain relief 4 days after the block....can theoretically dislodge a plaque....

did they do a post-mortem

Algos,

I have heard of spine surgeons stating that they often encounter 'pasty' steroids in the epidural space when they do decompressions on patients that received ESIs.

I have always been curious about the rate of clearance of depomedrol from the epidural space....if the spine surgeons are correct and not confusing steroids with localized epidural lipomatosis or atrophy of the LF...and steroids persist in the epidural space several days to weeks after and ESI....is it possible to have a delayed particulate emboli.....?

mind you the latter is theoretical and probably less plausible than snowfall in Lubbock during the summer...

I think you are absolutely correct about a post-hypertensive effect vs a slow venous-subdural-bleed in the setting of cervical stenosis and occult atherosclerosis/smoking or alternatively, an unrecognized Arnold Chiari malformation (assuming no pre-procedure MRI)/wet tap

We seem to hear about 'unpredictable' complications in interventional pain, more often than not...

Interesting...consider then the possibility of a vascular puncture (less likely in the posterior cervical epidural space than transforaminal or lumbar based on stats and anatomy) that develops a slow ooze. The particulates can remain for weeks but do slowly dissipate, and their particle size may be gradually reduced due to absorption...then the now smaller particle enters the bleed...
I like your other considerations also.
Lubbock? Snow? Never!

You are probably right...just poor timing. I have never read a case report or heard of delayed catastrophic events from an epidural steroid injection, but I believe there is a case of delayed transverse myelitis a week after epidural access. Most cases of catastrophic outcomes have an immediate (within a few minutes) onset.
Again, the posterior epidural cervical spine does not contain significant vasculature...

Still using depomedrol for ESI's??? This was an ischemic and not a hemorrhagic CVA, right?

T

algosdoc said:

Again, the posterior epidural cervical spine does not contain significant vasculature...

Click to expand...

And yet . . . I still seem to find it.

what's the chance of entering posterior spinal artery (arteries, since there are two of them) in doing interlaminar ESI?

I've never heard of it. Is it possible though? If it is, the theoretical risk of spinal ischemia is possible with IESI with particulate steroid.

did they stop plavix or coumadin on this patient prior to procedure?

drpainfree said:

what's the chance of entering posterior spinal artery (arteries, since there are two of them) in doing interlaminar ESI?

I've never heard of it. Is it possible though? If it is, the theoretical risk of spinal ischemia is possible with IESI with particulate steroid.

Click to expand...

Anything is possible, but whether it's probable is another story. You would have to be off mid-line and be in the intrathecal space. And even if you were, it wouldn't take 4 days for symptoms to manifest as is the case described above.

Several weeks ago I had vascular uptake on an interlaminar at C6-7. Removed needle, repeat at C7-T1, vascular again. Anyone would stop there as oppose to continuing to muck around some more?

drpainfree said:

what's the chance of entering posterior spinal artery (arteries, since there are two of them) in doing interlaminar ESI?

I've never heard of it. Is it possible though? If it is, the theoretical risk of spinal ischemia is possible with IESI with particulate steroid.

Click to expand...

Since the posterior spinal arteries run along the posterolateral aspect of the spinal cord, you'd have to go intrathecal to find them. My guess is you'd be more likely to hit the cord itself than find the artery.

But if you did - well, God help you and the patient and call your malpractice company right away. Right after you call a neurosurgeon.

There are also a few vessels that run with the cauda equina, but again, you'd have to be intrathecal to get them.

More worry is getting in the vessels that run within the epidural space - it is a fairly vascular area, and I'm sure we've all had intravascular uptake in there..

Is there anything in the literature regarding the incidence of post-epidural stroke, aside from it being rare?