Imaging: Fellow Case Report Poster - Imaging |

Iatrogenic Hemiparesis From Intramedullary Injection of Contrast FREE TO VIEW

Michael Bergman, MD; Lina Miyakawa, MD; Samuel Acquah, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):647A. doi:10.1016/j.chest.2016.08.741
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SESSION TITLE: Fellow Case Report Poster - Imaging

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Epidural injection of steroids (ESI) is a common treatment modality used for cervical neurogenic pain. The rate of complication is low, although higher overall rates are reported with cervical injections in comparison to the thoracic and lumbar areas. Here we present a case of iatrogenic hemiparesis from intramedullary spinal cord injection of contrast as a consequence of cervical myelography.

CASE PRESENTATION: A 55-year-old woman with chronic myelopathic pain presented to a clinic for a ESI. Pre-injection, she underwent a cervical myelogram to localize the epidural space. After the contrast injection, the patient had acute onset of left-sided chest pain. She was referred to the emergency department, where she complained of worsening pain in the shoulders and numbness in bilateral arms. Her neurologic exam revealed mild weakness of the right arm and paralysis of the left arm; there were absent reflexes and diminished pin prick on the left arm and leg. Cervical CT scan demonstrated dense material in the intramedullary space measuring 0.7x1.0 cm and extending from the cervico-cranial junction to T2-3 disc. A subsequent MRI confirmed these findings and also demonstrated mild cervical and thoracic cord edema. She was admitted to the MICU for monitoring given reported dyspnea; a NIF was normal at -60 cm H2O. She was given dexamethasone 10mg IV every 6 hours with subsequent improvement of her motor symptoms and dyspnea within 24 hours. At the time of hospital discharge she continued to have decreased sensation in her left arm and leg, namely to vibration and temperature. These sensory symptoms continued to persist on her one-month follow-up in clinic.

DISCUSSION: Epidural steroid injection is an increasingly common and generally low-risk procedure done for alleviation of neurogenic pain. Cervical injections carry a higher risk of complications due to narrower epidural spaces and proximity of the spinal cord. Rarely, direct intramedullary injection of contrast has been reported with permanent neurologic injury. It appears that the neurologic sequelae are nonprogressive and are related to the amount and characteristic of the injection material.

CONCLUSIONS: Neurological complications of epidural steroid injections are rare but can be serious. Given the risks, a high index of suspicion is required to help detect early signs of cord injury with appropriate early use of glucocorticoids to treat cord edema.

Reference #1: Benzon HT, et al. Improving the Safety of Epidural Steroid Injections. JAMA. 2015;313(17):1713-1714.

DISCLOSURE: The following authors have nothing to disclose: Michael Bergman, Lina Miyakawa, Samuel Acquah

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