1024 - When Relief Backfires: Complicated Recovery After Epidural Steroid Injection

Case Diagnosis: Complications following epidural steroid injection secondary to epidural blood patch   

Case Description: A 34-year-old male with chronic back pain underwent an L5-S1 interlaminar epidural injection with marcaine and dexamethasone and subsequently developed a headache. He returned to his physician days later and received a 60 mL epidural blood patch (EDBP). A few days after, he presented to the emergency department with persistent head pressure, worsening low back and bilateral leg pain. MRI showed a large epidural collection with severe compression of the thecal sac and bunching cauda equina nerve roots as well as blood products within the thecal sac. Fortunately, clinically he did not demonstrate acute cauda equina syndrome and was able to be managed conservatively for spinal headache and discharged with follow-up planned with his pain management provider.

Discussions: Puncture of the dura during a lumbar epidural injection can lead to spinal headache, described as severe, dull fronto-occipital pain, worse when upright and diminishes while supine, due to leakage of cerebrospinal fluid causing decrease in pressure on the brain and spinal cord. If analgesics and intravenous hydration fails, treatment with an EDBP is recommended. In this case, patient underwent a landmark guided 60 mL blood patch, with resulting compressive symptoms. Several guidelines recommend EDBP volumes of 10-20 mL. Based on physical exam, patient did not experience cauda equina syndrome requiring decompression, but experienced compressive symptomology likely secondary to the volume utilized causing thecal sac compression.

Conclusions: The risk of complications from a lumbar interlaminar epidural injection include infection, hematomas, intravascular injection, nerve trauma, or dural puncture, however with proper technique these complications are extremely rare. With regards to unintentional puncture of the dura resulting in spinal headache, treatment with EDBP consisting of 10-20mL autologous blood is recommended. Image guidance must also be considered on a case-by-case basis.