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Intra-arterial injection of particulate corticosteroids: mechanism of injury

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Abstract

Mechanism of neurologic complications after epidural spinal injections (ESI) of particulate steroids at the cervical spine include intrathecal injection, epidural hematoma, direct spinal cord injury, and brain stem or cord infarction due to an arterial spasm or inadvertent intra-arterial injection of particulate steroids. At the lumbar spine, there is evidence that a spinal cord infarction secondary to an inadvertent intra-arterial injection of particulate steroids through a transforaminal approach is the leading mechanism.

Variations in the arterial supply of the spinal cord help to understand how a lumbar ESI may lead to a spinal cord infarction at the thoracic level. A radiculomedullary artery arising from the lumbar or sacral spine may participate to the supply of the spinal cord. All radicular and radiculomedullary arteries penetrate the spinal canal through the intervertebral foramen. Therefore, its catheterization carries a risk of inadvertent intraarterial injection. An ex vivo animal study has shown that particulate steroids injected in the blood stream produce an immediate and unexpected change of red blood cells into spiculated cells which aggregate and cause arterioles obstruction, while no particulate steroid macroaggregates or vascular spasm were observed. Rare instances of neurologic complications also occurred after ESI performed through a posterior approach. All occurred in previously operated on patients suggesting a pathologic role for the epidural scar.

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References

  1. Racoosin JA, Seymour SM, Cascio L, Gill R. Serious neurologic events after epidural glucocorticoid injection–The FDA’s Risk Assessment. N Engl J Med. 2015;373:2299–301.

    Article  PubMed  Google Scholar 

  2. Wybier M, Gaudart S, Petrover D, Houdart E, Laredo JD. Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol. 2010;20(1):181–9.

    Article  PubMed  Google Scholar 

  3. Lasjaunias P, Berenstein A, ter Brugge KG. Spinal and spinal cord arteries and veins. In: clinical vascular anatomy and variations. Springer, Berlin, Heidelberg. 2001. https://doi.org/10.1007/978-3-662-10172-8_2

  4. Bert S, Iriboz AT, Barret F, Zouaoui A, Chiras J. An angiographic study of the spinal vascularization at the thoracic lumbar level. J Neuroradiol. 1995;22:12–9.

    CAS  PubMed  Google Scholar 

  5. Lo D, Vallée JN, Spelle L, Cormier E, Saillant G, Rancurel G, Chiras J. Unusual origin of the artery of Adamkiewicz from the fourth lumbar artery. Neuroradiol. 2002;44:153–7.

    Article  CAS  Google Scholar 

  6. Desproges-Gotteron R. Contribution à l’étude de la sciatique paralytique. Thèse Médecine. Paris. 1955 N°342.

  7. de Sèze Guillaume J, Desproges-Gotteron R, Jurmand SH, Maitre M. Sciatique paralysante (Etude clinique, pathogénique, thérapeutique d’après 100 observations). Sem Hôp Paris. 1957;28:548–72.

    Google Scholar 

  8. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain A prospective randomized controlled double-blind study. J Bone Joint Surg Am. 2000;82:1589–93.

    Article  CAS  PubMed  Google Scholar 

  9. Djindjian R, Hurth M, Houdart R. Angiography of the spinal cord. Masson Paris 1969: 1–26.

  10. Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res. 1986;207:37–43.

    Article  Google Scholar 

  11. Park JW, Nam HS, Park Y. Kambin’s triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med. 2011;36(6):833–43.

    Article  Google Scholar 

  12. Simon JI, McAuliffe M, Smoger D. Location of radicular spinal arteries in the lumbar spine from analysis of CT angiograms of the abdomen and pelvis. Pain Med. 2016;17(1):46–51.

    PubMed  Google Scholar 

  13. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4(4):468–74.

    Article  PubMed  Google Scholar 

  14. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think ? Spine. 2007;32(11):1249–56.

    Article  PubMed  Google Scholar 

  15. Glaser SE, Falco F. Paraplegia following a thoracolumbar transforaminal epidural steroid injection. Pain Physician. 2005;8(3):309–14.

    Article  PubMed  Google Scholar 

  16. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spine epidural steroid injection: two case reports. Pain Med. 2009;10(8):1389–94.

    Article  PubMed  Google Scholar 

  17. Lyders EM, Morris PP. A case of spinal cord infarction following lumbar transforaminal epidural steroid injection: MR imaging and angiographic findings. AJNR Am J Neuroradiol. 2009;30(9):1691–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Somayaji HS, Saifuddin A, Casey AT, Briggs TW. Spinal cord infarction following therapeutic computed tomography-guided left L2 nerve root injection. Spine. 2005;30(4):E106–8.

    Article  CAS  PubMed  Google Scholar 

  19. Okubadejo GO, Talcott MR, Schmidt RE, et al. Perils of intravascular methylprednisolone injection into the vertebral artery. An animal study. J Bone Joint Surg Am. 2008;90(9):1932–8.

    Article  PubMed  Google Scholar 

  20. Dawley JD, Moeller-Bertram T, Wallace MS, Patel PM. Intra-arterial injection in the rat brain: evaluation of steroids used for transforaminal epidurals. Spine. 2009;34(16):1638–43.

    Article  PubMed  Google Scholar 

  21. MacMahon PJ, Shelly MJ, Scholz D, Eustace SJ, Kavanagh EC. Injectable corticosteroid preparations: an embolic risk assessment by static and dynamic microscopic analysis. AJNR Am J Neuroradiol. 2011;32(10):1830–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9(2):227–34.

    Article  PubMed  Google Scholar 

  23. Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiol. 2007;106(2):331–8.

    Article  CAS  Google Scholar 

  24. Laemmel E, Segal N, Mirshahi M, Wybier M, Vicaut E, Laredo JD. Deleterious effects of intra-arterial administration of particulate steroids on microvascular perfusion in a mouse model. Radiol. 2016;279:731–40.

    Article  Google Scholar 

  25. Laredo JD, Laemmel E, Vicaut E. Serious neurological events complicating epidural injections of glucocorticoid suspensions: evidence for a direct effect of some particulate steroids on red blood cells. RMD Open. 2016;2(2):e000320.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Annaswamy TM, Worchel L. Paraplegia following lumbar epidural steroid injection in a patient with a spinal dural arteriovenous fistula. Am J Phys Med Rehabil. 2017;96(8):e147–50. https://doi.org/10.1097/PHM.0000000000000645.

    Article  PubMed  Google Scholar 

  27. Saito H, Hida K, Asano T, et al. Conus perimedullary arteriovenous fistula with multiple shunt points including the cauda equina: a case report]. [Article in Japanese. No Shinkei Geka. 2011;39(4):375–80.

    PubMed  Google Scholar 

  28. Kim S, Choi Y, Park J, Sung DH. Acute paraplegia after lumbar steroid injection in patients with spinal dural arteriovenous fistulas: case reports. Ann Rehabil Med. 2016;40(5):949–54.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Clemens HJ. Die Venesysteme der menschlichen Wirbelsaule. Berlin: Walter de Gruyter; 1961.

    Google Scholar 

  30. Parke WW. Role of epidural and radicular veins in chronic back pain and radiculopathy. In: Arthroscopic and Endoscopic Spinal Surgery. Ed: Kambin P. Second edition. Humana Press Inc. Totowa, NJ. 2005.

  31. Thefenne L, Dubecq C, Zing E, et al. A rare case of paraplegia complicating a lumbar epidural infiltration. Ann Physical Rehabil Med. 2010;53:575–83.

    Article  CAS  Google Scholar 

  32. Meyer R, Kieffer D, Vautravers P, Kuntz JL, Asch L. Paraplégie après infiltrations épidurales cortisoniques. Rhumatologie. 1979;31:339–41.

    Google Scholar 

  33. Lenoir T, Deloin X, Dauzac C, Rillardon L, Guigui P. Paraplegia after interlaminar epidural injection: a case report. Rev Chir Orthop. 2008;94(7):697–701.

    CAS  PubMed  Google Scholar 

  34. Ross JS, Modic MT, Masaryk TJ, Carter J, Marcus RE, Bohlman H. Assessment of extradural degenerative disease with Gd-DTPA-enhanced MR imaging: correlation with surgical and pathologic findings. Am J Neuroradiol. 1989;10:1243–9.

    CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Service de Chirurgie Orthopédique Et Traumatologique, Hôpital Lariboisière. Assistance Publique des Hôpitaux de Paris, 2, Rue Ambroise Paré, 75010, Paris, France

    Jean-Denis Laredo

  2. Centre de Radiologie Cortambert, Paris 75116, Paris, France

    Marc Wybier

  3. INSERM U942, Université Paris Cité, Paris, France

    Elisabeth Laemmel

  4. INSERM 1275, Université Paris Cité, Paris, France

    Massoud Mirshahi

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  1. Jean-Denis Laredo
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  2. Marc Wybier
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  3. Elisabeth Laemmel
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  4. Massoud Mirshahi
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Correspondence to Jean-Denis Laredo.

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Laredo, JD., Wybier, M., Laemmel, E. et al. Intra-arterial injection of particulate corticosteroids: mechanism of injury. Skeletal Radiol 52, 1887–1892 (2023). https://doi.org/10.1007/s00256-022-04273-5

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  • DOI: https://doi.org/10.1007/s00256-022-04273-5

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