Acute Intracranial Subdural Hematoma After Epidural Steroid Injection: A Case Report

doi:10.1016/j.jmpt.2007.07.005

Journal of Manipulative and Physiological Therapeutics

Volume 30, Issue 7, September 2007, Pages 536-538

https://doi.org/10.1016/j.jmpt.2007.07.005 Get rights and content

Abstract

Objective

Conservative treatment of lumbar radiculopathy includes bed rest, oral medications, physical therapy, spinal manipulation, mobilization, and epidural steroid injections. Intracranial subdural hematoma after accidental dural puncture is a rare and life-threatening complication of epidural steroid injections. In this report, we present a case of subacute intracranial subdural hematoma that developed after epidural steroid injection.

Clinical Features

A 40-year-old man was admitted to our clinic with severe persistent headache and vomiting for 2 days after epidural steroid injection for right leg pain.

Intervention and Outcome

The patient was hospitalized for epidural steroid injection for right leg pain in our pain clinic and was discharged the same day. Twenty-four hours later, he started having a headache. Despite the use of oral analgesics, his headache worsened, and he began to vomit particularly in the upright position. Magnetic resonance imaging of the brain displayed a right frontal subdural hematoma. The headache was relieved after strict bed rest, intravenous hydration, and analgesics. The patient was discharged with full recovery after 1 week.

Conclusion

Intracranial subdural hematoma after accidental dural puncture during epidural steroid injection is a rare complication. Persistent headache should be evaluated carefully for possible intracranial hematomas.

Section snippets

Case Report

A 40-year-old man was admitted to our hospital with severe headache and vomiting. Results of his neurologic examination were normal. Assuming an upright position significantly worsened the headache. His medical history was unremarkable except that he was hospitalized for a same-day ESI for right leg pain in our pain clinic and was discharged 3 days before admission to hospital for headache. Twenty-four hours after injection is when the headache began. This headache worsened despite the use of

Discussion

Epidural steroid injection has an important place in the conservative treatment of lumbosacral radiculopathy resulting from lumbar disk herniation and/or stenosis.² Complications of this procedure are rare and reported at a rate of 9.6% by Botwin et al.⁴ Nevertheless, major complications including intracranial subdural air, spinal subdural hematoma, and cauda equina syndrome after ESI are reported as isolated cases in the literature.2, 5, 6 In their recent review of the literature, Abdi et al⁷

Conclusion

Although epidural steroids appear to be safe and effective in the conservative treatment of lumbar radiculopathy, intracranial subdural hematomas may occur as a rare complication of ESI. Patients should be followed for the development of subsequent complications in case of accidental dural puncture. Persistent and intractable headache that does not resolve with recumbency could indicate intracranial subdural hematoma, and patients should be considered for cranial imaging.

Practical Applications

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Epidural steroid

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Cited by (21)

Epidural corticosteroid injection complicated by a subdural hematoma: A new case
2020, Revue du Rhumatisme (Edition Francaise)
Les infiltrations épidurales de corticostéroïdes constituent un traitement classique des lomboradiculalgies. La description d’événements neurologiques grave par la Food and Drug Administration (FDA) conduit à se poser la question du bénéfice-risque de cette pratique. Cas clinique : une femme caucasienne, âgée de 55 ans, est hospitalisée pour la prise en charge d’une lombosciatique de trajet S1 droite. Au cours de l’hospitalisation sont réalisées à 48 heures d’intervalle, 2 infiltrations épidurales par voie interépineuse sous repérage anatomique à l’aide d’une aiguille spinale de dimension 20 gauge 0,90 × 88 mm. Un corticoïde particulaire est utilisé, à savoir une ampoule de 5 mL d’acétate d’hydrocortisone pour chaque geste infiltratif. À j5 de la sortie d’hospitalisation, la patiente présente des céphalées accompagnées de vertiges se majorant à la position orthostatique. Un scanner cérébral sans injection est effectué. Celui-ci retrouve un hématome sous dural subaigu de localisation fronto-pariétale gauche s’étendant à la tente du cervelet gauche, d’environ 4 mm d’épaisseur. Il n’est pas retenu d’indication neurochirurgicale devant l’absence de signe de focalisation et la stabilité de l’hématome. La symptomatologie s’améliore après 48 h d’hydratation IV et le respect du décubitus strict. Conclusion : une surveillance rapprochée est nécessaire dans les suites d’une infiltration épidurale. La présence de céphalées persistantes secondairement à une infiltration épidurale exige un examen neurologique approfondi. Une imagerie cérébrale doit parfois être envisagée afin de ne pas méconnaître une étiologie intracérébrale potentiellement fatale. Nous recommandons un repos strict au lit dans les suites immédiates d’une infiltration épidurale.
Efficacy of epidural methylprednisolone in radicular pain
2015, Revista Colombiana de Anestesiologia
Citation Excerpt :
The main risk factor for their occurrence is a history of diabetes mellitus.35,38 Haemorrhagic complications associated with the procedure include acute subdural as well as epidural and subarachnoidal haematomas.41,42 From the neurological standpoint there may be transient motor weakness, cauda equina syndrome (very few cases reported) with symptoms usually resolving within hours or days; there may also be direct neurological damage.43–45
Degenerative disc disease is a prevalent and disabling disease. When the conservative treatment fails to obtain pain relief, epidural steroids are an alternative frequently used worldwide.
To evaluate the efficacy and safety of epidural methylprednisolone in patients with radicular pain.
Descriptive longitudinal retrospective study in patients with chronic radicular pain who received fluoroscopy-guided interventional treatment, between July 2010 and December 2011 at Instituto Colombiano del Dolor (Medellín-Colombia), to determine the efficacy and safety of epidural methylprednisolone in clinical practice. Pain relief was followed using the visual analogue scale, during at least 8 weeks.
254 patients were analyzed. The mean age of the patients was 52.8 years (SD ± 15); 52.8% were men. The main diagnosis was lower-limb radicular pain (87.7%). The most frequent procedures were transforaminal lumbar injection (54.3%) and interlaminar lumbar injection (17.7%). The proportion of patients with more than 50% pain relief 50% was 85.8%. There were no differences in efficacy between the procedures. Pain improvement lasted more than 8 weeks in 55% of patients. The incidence of complications was lower than 1%.
When radicular pain is refractory to conservative treatment based on pharmacological and physical therapy, epidural methylprednisolone is an effective and safe method in our setting.
La enfermedad discal degenerativa es una enfermedad muy prevalente e incapacitante. Cuando el manejo conservador falla los esteroides epidurales son una alternativa de uso frecuente en todo el mundo.
Evaluar la eficacia y seguridad de la metilprednisolona epidural en pacientes con dolor radicular.
Estudio descriptivo longitudinal retrospectivo, en pacientes con dolor radicular crónico que recibieron tratamiento intervencionista guiado por fluoroscopia en el Instituto Colombiano del Dolor (Medellín-Colombia) en el período comprendido entre julio de 2010 y diciembre de 2011, para determinar la eficacia clínica y seguridad de la metilprednisolona epidural. Se realizó seguimiento del control del dolor medido por escala visual análoga por al menos 8 semanas.
Se analizaron 254 pacientes. La edad promedio de los pacientes intervenidos fue de 52,8 años (DE ± 15), el 52,8% fueron hombres. El principal diagnóstico fue el dolor radicular en los miembros inferiores (87,7%). Los procedimientos más frecuentes fueron; inyección transforaminal lumbar (54,3%) e inyección interlaminar lumbar (17,7%). El 85.8% de los pacientes presentó disminución del dolor mayor al 50%. No hubo diferencias en la eficacia entre los diferentes bloqueos. En el 55% de los pacientes el tiempo de mejoría fue superior a 8 semanas. La incidencia de complicaciones fue menor al 1%.
Cuando el dolor radicular es refractario al tratamiento conservador basado en terapia farmacológica y física, la metilprednisolona epidural es un método eficaz y seguro disponible en nuestro medio.
Epidural steroid injections: Complications and management
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Citation Excerpt :
Typically, it is treated with strict bed rest, hydration and analgesics, as well as an epidural blood patch; however, in patients with progressive neurologic deficits or loss of consciousness, surgical decompression may be necessary.123 Few isolated cases have been reported in the literature.124,125 Very few cases of subdural hematomas have been reported in the literature, but most are associated with an underlying coagulopathy.
Epidural steroid injections (ESIs) are a form of interventional therapy broadly used worldwide for the treatment of pain. Although generally considered a safe treatment, with a low incidence of complications, these may range from very mild and transient symptoms to truly catastrophic events, including brain damage, spinal cord injury and death. Even when proper technique is used, sufficient training in interventional pain medicine is obtained, and adequate safety measures are taken, fatal events can occur. The purpose of this review article is to examine the reported complications of ESIs and suggested negative outcome management.
Spinal Injection Procedures: A Review of Concepts, Controversies, and Complications
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Citation Excerpt :
Huston and colleagues254 reported an incidence of 0.33% when performing cervical and lumbosacral selective nerve root injections. Dural puncture can result in CSF leak with possible intracranial hypotension, arachnoiditis, and transient paraparesis/cauda equina symptomatology in the setting of inadvertent intrathecal injection of medications, and even pneumocephalus with resultant severe headache.255–258 The most extreme complication reported is an intramedullary injection resulting in paralysis.259
The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.
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Case ReportAcute Intracranial Subdural Hematoma After Epidural Steroid Injection: A Case Report

Abstract

Objective

Clinical Features

Intervention and Outcome

Conclusion

Section snippets

Case Report

Discussion

Conclusion

Practical Applications

J Manipulative Physiol Ther

Br J Anaesth

Arch Phys Med Rehabil

Br J Anaesth

Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study

Spine

Case Report
Acute Intracranial Subdural Hematoma After Epidural Steroid Injection: A Case Report