Case Report
Stroke following Epidural Injections—Case Report
and Review of Literature
Alexandra Popescu, MD, Daniel Lai, MD, Angela Lu, MD, Kathy Gardner, MD
From the Department of Neurology, Epilepsy Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (AP); Department of Neurology, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (DL); and Division of General Neurology, Department of Neurology, University of Pittsburgh School of Medicine,
Pittsburgh, Pennsylvania (AL, KG).

ABSTRACT
BACKGROUND AND PURPOSE

To describe a growing number of cases associated with spinal cord and posterior circulation
ischemia as a complication of cervical epidural steroid injection (CESI).
METHODS

Case report and review of literature.
RESULTS

Keywords: Infarction,
steroids.

spinal

cord,

Acceptance: Received October 3, 2010,
and in revised form February 13, 2011.
Accepted for publication March 15, 2011.

CONCLUSION

Correspondence: Address correspondence to Daniel Lai, MD, Suite 811,
Kaufmann Medical Building, 3471 Fifth
Avenue, Pittsburgh, PA 15213. E-mail:
laidk@upmc.edu.

Infarction is a rare but potentially devastating complication of CESI. It may occur despite
the use of fluoroscopic guidance.

Conflict of Interest: None.

Sixteen cases of spinal cord and posterior circulation ischemia were analyzed. Two cases
had transient symptoms and 10 had long-term sequelae. Four resulted in death.

J Neuroimaging 2011;XX:1-4.
DOI: 10.1111/j.1552-6569.2011.00615.x

Introduction
Cervical epidural steroid injection (CESI) is used to conservatively manage intractable radicular pain. Despite the lack of
prospective trials, steroid injection is considered safe and efficacious. The two approaches for cervical injection are transforaminal and interlaminar. The transforaminal injection has
the advantage of directly delivering the injectate onto the target
nerve by entering through the foramen tangential to its posterior wall. The procedure requires fluoroscopic guidance to allow
direct visualization of the epidural space and vertebral artery.
The vertebral artery rises closely in front of the zygapophysial
joint.1 Following needle drawback negative for cerebrospinal
fluid (CSF) or blood, contrast is injected and spreads first within
the intervertebral foramen then into the epidural space until
the dural sleeve is outlined. Next, a small volume of local anesthetic is injected, followed by corticosteroid. The procedure is
performed on an outpatient basis and is thought to have a low
complication rate. Neurologic sequelae following CESI have
been reported as increased pain (7%), transient nonpositional
headache (5%), vasovagal reaction (2%), facial flushing (1.5%),
and dural puncture (.3%).1

Case Report
A 66-year-old woman underwent transforaminal CESI for relief
of intractable neck and shoulder pain. Under fluoroscopic guidance using Isovue dye, a 22-guage Quicke needle was placed

and its position confirmed. Forty milligrams of methylprednisolone acetate was injected at the C5-C6 level. The patient
developed flaccid quadriplegia within 45 minutes. Magnetic resonance imaging (MRI) obtained 2 hours postprocedure showed
no signs of hemorrhage. The patient was administered methylprednisolone 125 mg intravenously and transferred to our facility. Neurological examination revealed intact mental status
and cranial nerves. There was flaccid quadriplegia with a C5
dissociated sensory level. Vibratory sensation and proprioception were preserved but there was loss of sensation to pinprick
and temperature below C5. Reflexes were absent, rectal tone
was decreased, and Babinski reflex was present bilaterally. The
MRI showed a longitudinal gadolinium-enhancing lesion from
C3 to T2 with an “owl’s eyes” pattern present at C5 (Fig 1A, B)
16 hours postprocedure. On postprocedure day 2, a repeat MRI
showed edema of the entire cervical spinal cord and restricted
diffusion at C4-C6, confirming our clinical suspicion of a cord
infarction (Fig 1C, D). MRI of the brain with axial T1-weighted
fat-suppression images and MRA of intracranial and extracranial vessels were negative for vertebral artery dissection. By the
third week, the patient remained quadriplegic and repeat MRI
showed resolving spinal cord edema.
We conducted a literature search for cases of neurologic
complications related to CESI on PubMed using MeSH results
with the following search terms: spinal cord, infarction, cervical, steroid, transforaminal, injection. We present 16 cases, 15

â—¦

Copyright C 2011 by the American Society of Neuroimaging

1

Discussion

Fig 1. Gadolinium-enhanced T1-weighted images revealed enhancement at C3-T2 levels (A) predominantly in the anterior gray
matter with an “owl’s eyes” pattern the level of C5 (B). MRI postprocedure day 2 showed edema of the entire cervical spinal cord (C)
and restricted diffusion at C4-C6 levels (D).

of which were found on review of the literature. Methods were
characterized according to whether the procedure was typical,
that is, fluoroscopy confirmed needle placement with negative
aspiration of both blood and CSF, or atypical where fluoroscopy
was unused, aspiration was positive or the procedure was otherwise unspecified.

2

Journal of Neuroimaging Vol xx No x 2011

A survey of 1,340 pain specialists (287 responders)2 reported 78 complications following transforaminal CESI in their
cumulative experience. These included 30 infarction cases
(brain and/or spinal cord) with 13 cases resulting in fatality.
Our literature review found six cases of posterior circulation infarction (three typical, three atypical procedures) and 10 cases
of spinal cord ischemia (three typical, seven atypical procedures) following CESI (one case with both cord and cerebellar
infarction).
Our case demonstrated that with fluoroscopic guidance and
negative needle aspiration an extensive anterior spinal artery
cord infarct can occur in the absence of vertebral artery dissection. The injury was likely due to ischemia in the distribution
of a radicular artery that feeds the anterior spinal artery. Furman et al3 reported a study with 504 transforaminal cervical
injections and found a 19.4% rate of fluoroscopy-confirmed intravascular injections despite no blood on needle drawback.
Needle flashback for blood was estimated to be 97% specific,
but only 45.9% sensitive for identifying intravascular injection.3
An anatomic dissection of 95 cervical intervertebral foramina
showed an arterial vessel proximal to the posterior aspect of
the foraminal opening in 21 cases. Seven of eight spinal arterial
branches from the ascending or deep cervical artery entered
posteriorly.4 Thus, the posterior placement of the needle does
not exclude the possibility of vascular injury despite avoiding
the vertebral artery. It is possible to inject an artery even if no
blood is seen on needle drawback due to the low sensitivity of
this method, and possibly even if position is verified using fluoroscopy according to the result of our case and those reported
in Table 1.
Periprocedure infarctions due to either vasospasm or an embolus from particulate matter associated with the steroid injection have been postulated as mechanisms for causing neurologic symptoms. A review of this case series shows that of the
16 cases, 12 (75%) involved injection of steroids. Scalon et al
found a rate of 90% of cases involved in neurologic complications were associated with steroid injection, 79% of which
involved methylprednisolone use.2 Tiso et al suggest that corticosteriod suspensions contain particles which may occlude
arterioles.5
Steriods were used in 12 of the reported cases in this series. Of the 12 cases, at least 10 reported long-term neurologic
consequences ranging from severe paresis to death (two case
outcomes are unknown). The four cases without known steriod
use seem to exhibit a more benign case with outcomes ranging
from a single fixed deficit to complete resolution.6-9 More data
are needed to determine the efficacy of transforaminal injections. Anderberg et al reported a study of 40 patients showed
that injection of a combination of steroid with local anesthetic
lacked superiority in symptom relief when compared with injection of local anesthetic combined with saline.10
Infarction is a rare but potentially devastating complication
of CESI. It may occur despite the use of fluoroscopic guidance.
Patients and practitioners need to be aware that there is a risk
of spinal cord and brain infarction related to the transforaminal
CESI and that both safety and efficacy for the procedure are in
question.

Table 1. Anaylsis of Cases of Spinal Cord and Posterior Circulation Ischemia
Case/
Reference

Injection
Site

1

Presentation/Clinical
Course

Medications

Method

C5-C6

Methylprednisolone

Typical

212

(R)C5-C6

Triamcinolone
Bupivacaine

Typical

313

(L)C5-C6

Triamcinolone
Bupivacaine

Typical

46

C6-C7

Methylprednisolone

Atypical

515

(L)C5-6
(L)C6-7

Methylprednisolone
Bupivacaine

Atypical

614

(R)C6-C7

Lidocaine

Atypical

718

(L)C6-C7
(L)C7-C8

Steriod not named

Atypical

87

(L)C5-C6

Unknown

Atypical

Confusion, (L) arm
weakness

919

(L)C6-C7

Triamcinolone
Mepivacaine

Atypical

108

(L)C6-C7

None (contrast only)

Atypical

Flaccid quadriplegia,
respiratory arrest, C4
sensory level
Quadriparesis, (L)C6
sensory level

115

(R)C5-C6

Triamcinolone
Bupivacaine

Typical

1216

(R)C7-T1

Methylprednisolone
Lidocaine

Typical

1317

(L)C5-C6

Methylprednisolone

Typical

1418

(L)C5-C6

Betamethasone
Lidocaine

Atypical

159

(L)C5-C6

Anesthetics,
unspecificed

Atypical

1611

(L)C6-C7

Methylprednisolone
Bupivacaine

Atypical

Flaccid quadriplegia,
dissociative sensory
loss with C5 level
Flaccid paralysis,
transient coma then
quadriplegic
Quadriplegia,
dissociative sensory
loss
Quadriplegic,
respiratory arrest
Arms paretic with
paraplegia, T4
sensory level
Transient quadriparesis,
dissociative sensory
loss
Numbness and
weakness of (L) arm

Transient
unresponsiveness,
quadriplegia
Neck pain, headache,
nausea then
intermittent apnea,
posturing
Nausea, vomiting and
headache followed by
decreased
consciousness and
dysarthria
Transient
unresponsiveness.
Dysarthria, ataxia,
numb arms, (L) arm
plegic, (R) arm paretic
Nystagmus. Subsequent
blindness, seizures,
obtundation, aphasia,
dysphagia
Immediately
noncommunicative

Investigations

Outcome

MRI: cord infarct at
C4-C6

3 weeks: quadriplegic

MRI: extensive cord
infarction

Death

MRI: extensive cord
infarction C2-T1

Unknown

MRI: no infarction

6 months: regained some
strength requiring daily
assistance
8 weeks: ambulating with
walker

MRI: cervical cord
edema and medullary
infarction
None

MRI: petechial
hemorrhages in
lateral cord
CT: dissection of left
vertebral artery at (L)
C3-C6
MRI: high cervical to
upper thoracic cord
edema
CT: intracord air bubble
MRI: cervical cord
edema
MRI: cerebellar infarct.

MRI: cerebellar infarct
with edema and
subsequent herniation
MRI: midbrain, pons, L
thalamic infarction.

20 minutes: resolution

(L) C7 radiculopathy with
weakness and numbness
24 hours: resolution

3 months: breathing
unassisted
(L) arm paresis otherwise
restored strength
Death

Posterior fossa craniectomy
and meningitis.
Recovered with diplopia
and memory deficits
Death

MRI: cerebellar infarct
and C1-C4 cord
infarct

Unknown

MRI: L occipital cortex
cerebral edema

Day 30: memory deficits
and (R) homonymous
hemianopia

CT: brainstem
hemorrhage,
intraventricular
hemorrhage

Death

(L) =left; (R) = right; (C) = cervical.

Popescu et al: Stroke following Epidural Injections

3

References
1. Rathmell J, Aprill C, Bogduk N. Cervical transforaminal injection
of steroids. Anesthesiology 2004;100:1595-1600.
2. Scalon GC, Moeller-Bertram T, Romanowsky SM, et al. Cervical
transforaminal epidural steroid injections: more dangerous than
we think? Spine 2007;32:1249-1256.
3. Furman MB, Giovanniello MT, O’Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid
injections. Spine 2003;28:21-25.
4. Huntoon M. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections.Pain 2005;117:104-111.
5. Tiso RL, Cutler T, Catania JA, et al. Adverse central nervous
system sequelae after selective transforaminal block: the role of
corticosteroids. Spine J 2004;4:468-474.
6. Karasek M, Bogduk N. Temporary neurologic deficit after cervical
transforaminal injection of local anesthetic. Pain Med 2004;5:202205.
7. Wallace MA, Fukui MB, Williams RL, et al. Complications of cervical selective nerve blocks performed with fluoroscopic guidance.
AJR Am J Roetgenol 2007;188:1218-1221.
8. Lee JH, Lee JK, Seo BR, et al. Spinal cord injury produced by
direct damage during cervical transforaminal epidural injection.
Reg Anesth Pain Med 2008;33:377-379.
9. McMillian MR, Crumpton C. Cortical blindness and neurologic
injury complicating cervical transforaminal injection for cervical
radiculopathy. Anesthesiology 2003;99:509-511.
10. Anderberg L, Annertz M, Persson L, et al. Transforaminal steroid
injections for the treatment of cervical radiculopathy: a prospective
and randomized study. Eur Spine J 2007;16:321-328.

4

Journal of Neuroimaging Vol xx No x 2011

11. Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation
of the left vertebral artery. Am J Forensic Med Pathol 2003;24:
351-355.
12. Brouwers PJ, Kottink EJ, Simon MA, et al. A cervical anterior
spinal artery syndrome after diagnostic blockade of the right C6nerve root. Pain 2001;91:397-399.
13. Ludwig MA, Burns SP. Spinal cord infarction following cervical transforaminal epidural injection: a case report. Spine
2005;30:E266-E268.
14. Bose B. Quadriparesis following cervical epidural steroid injections: case report and review of the literature. Spine J 2005;5:558563.
15. Muro K, O’Shaughnessy B, Ganju A. Infarction of the cervical
spinal cord following multilevel transforaminal epidural steroid
injection: case report and review of the literature. J Spinal Cord
Med 2007;30:385-388.
16. Beckman WA, Mendez RJ, Paine GF, et al. Cerebellar herniation
after cervical transforaminal epidural injection. Reg Anesth Pain Med
2006;31:282-285.
17. Ziai WC, Ardelt AA, Llinas RH. Brainstem stroke following
uncomplicated cervical epidural steroid injection. Arch Neurol
2006;63:1643-1646.
18. Windsor RE, Storm S, Sugar R, et al. Cervical transforaminal injection: review of the literature, complications, and a suggested technique. Pain Physician 2003;6:457465.
19. Rosenkranz M, Grzyska U, Niesen W, et al. Anterior spinal artery
syndrome following periradicular cervical nerve root therapy. J
Neurol 2004;251:229-231.