Endovascular treatment for acute paraplegia after epidural steroid injection in a patient with spinal dural arteriovenous malformation

Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain

BACKGROUND AND PURPOSE

The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation.

MATERIAL AND METHODS

We retrospectively evaluated 18 patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization.

RESULTS

Acute postoperative worsening within 1 week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as a procedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. A comparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274).

CONCLUSION

The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.

Paralysis After Lumbar Interlaminar Epidural Steroid Injection in the Absence of Hematoma: A Case of Congestive Myelopathy Due to Spinal Dural Arteriovenous Fistula and a Review of the Literature

Paraplegia after interlaminar epidural steroid injection is a rare event and has typically been described after epidural hematoma or direct spinal cord injury. We present a case of an 87-yr-old man who experienced transient lower limb weakness after a lumbar interlaminar epidural steroid injection due to an alternative cause, congestive myelopathy related to an underlying vascular malformation, namely, a spinal dural arteriovenous fistula. This is a poorly recognized and potentially treatable cause of progressive myelopathy. We present this case and review the literature on paraplegia after epidural steroid injection due to spinal dural arteriovenous fistula. Notably, this case of paralysis occurred in association with the lowest volume of epidural injectate reported in the literature to date (4 ml); importantly, this volume is consistent with the current clinical practice guideline standards for the safe performance of interlaminar epidural steroid injections. Physicians should be aware of this potential complication of epidural steroid injection and remain vigilant for the possibility after a procedure, even when performed according to current practice standards.

Steroid-Associated Acute Clinical Worsening and Poor Outcome in Patients With Spinal Dural Arteriovenous Fistulas: A Prospective Cohort Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

We conducted a prospective cohort study to identify the association between steroids and clinical worsening and compare outcomes between patients with and without preoperative steroid administration.

SUMMARY OF BACKGROUND DATA

Patients with spinal dural arteriovenous fistulas (SDAVFs) often were misdiagnosed and treated with steroids which led to acute worsening.

METHODS

Patients with angiographically confirmed SDAVFs were recruited consecutively between March 2013 and December 2014 in two referral centers. We reviewed the history of all the patients to identify those patients who were treated with steroids before exclusion of the fistulas. Modified Aminoff & Logue scale (mALS) was used to evaluate the spinal cord function at different time points: before and after steroid administration, before operation, and at 1-year follow-up. Paired t tests were used to assess the mALS of patients with steroid administration at different time points. Unpaired t tests and Pearson chi-square test were used to assess differences between patients with and without steroid administration.

RESULTS

Eighteen patients with (18.2%) and 81 patients without (81.8%) steroid administration were included in this study. At baseline, there were no difference between both patient groups, in regards to age, sex, duration, location of fistula, treatment, and preoperative mALS. Patients without steroid administration, however, had statistically significant better outcome according to their mALS at 1-year follow-up (P < 0.05).

CONCLUSION

Steroid administration can induce acute clinical worsening in patients with SDAVFs that may persist despite successful obliteration of the fistula and should thus be avoided.

LEVEL OF EVIDENCE

3.

Paraplegia Following Lumbar Epidural Steroid Injection in a Patient With a Spinal Dural Arteriovenous Fistula

We report a patient with a previously undiagnosed spinal dural arteriovenous fistula (SDAVF) who became acutely paraplegic following a lumbar epidural steroid injection for lumbar spinal stenosis. Magnetic resonance imaging showed multiple flow voids and serpentine vessels on the cord surface with cord edema extending from T3 through the conus. Spinal angiography confirmed an SDAVF fed by the left lateral sacral artery, which was subsequently endovascularly embolized, and the patient had a partial return of function. Presence of an undiagnosed SDAVF should be considered in patients presenting with lower-extremity weakness without pain and considered a contraindication to lumbar epidural steroid injection.

Acute Paraplegia After Lumbar Steroid Injection in Patients With Spinal Dural Arteriovenous Fistulas: Case Reports

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations. However, SDAVFs are still underdiagnosed entities because their clinical symptoms are usually non-specific, as they include low back pain or radiating pain to the limb. There have been several reports of acute paraplegia after lumbar epidural steroid injections in patients with SDAVFs. We present 4 patients with SDAVFs who received lumbar steroid injection. Among the 4 cases, acute paraplegia developed in 2 cases that received a larger volume of injectate than the other cases. Thus, we are suggesting that the volume of injectate may be a contributing factor for acute paraplegia after lumbar steroid injection in patients with SDAVFs.

Delayed onset paraparesis complicating epidural steroid injection with underlying spinal dural arteriovenous fistula

We report a case of a 48-year-old man with chronic back pain attributed to discogenic lumbar radiculopathy who underwent a fluoroscopy-guided L2-3 interlaminar epidural steroid injection. 4 h later, he developed acute paraparesis, sensory loss below T10 level and urinary retention. MRI of the thoracic spine revealed diffuse abnormal T2/FLAIR signal and extensive vascular flow voids. A spinal dural arteriovenous fistula was confirmed on spinal angiography. Embolization of the spinal dural arteriovenous fistula resulted in significant improvement of symptoms. We review previously reported cases and current understanding of the pathophysiology of this complication. All cases had symptom onset several hours after the procedure. There seems to be a trend toward better outcomes with earlier treatment.

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data

OBJECTIVE

To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections.

DESIGN

Systematic review.

INTERVENTIONS

Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented.

OUTCOME MEASURES

The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence.

RESULTS

The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low.

CONCLUSIONS

In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.

Paraplegia following intercostal nerve neurolysis with alcohol and thoracic epidural injection in lung cancer patient

The goal of cancer treatment is generally pain reduction and function recovery. However, drug therapy does not treat pain adequately in approximately 43% of patients, and the latter may have to undergo a nerve block or neurolysis. In the case reported here, a 42-year-old female patient with lung cancer (adenocarcinoma) developed paraplegia after receiving T8-10 and 11^th intercostal nerve neurolysis and T9-10 interlaminar epidural steroid injections. An MRI results revealed extensive swelling of the spinal cord between the T4 spinal cord and conus medullaris, and T5, 7-11, and L1 bone metastasis. Although steroid therapy was administered, the paraplegia did not improve.

Spinal dural arteriovenous fistula presenting with paraplegia following lumbar puncture

Spinal dural arteriovenous fistulas are rare lesions with an annual incidence of 1 per 100,000 population. In patients with this disease, an abnormal vascular dural shunt exists between a dural branch of a segmental artery and a subdural radicular vein that drains the perimedullary venous system, leading to venous hypertension and secondary congestive myelopathy. Generally, patients present with progressive paraparesis, urinary disturbances, and gait ataxia. In this report the authors describe a 61-year-old woman with a spinal dural arteriovenous fistula who developed an acute paraplegia after a nontraumatic lumbar puncture. The possible underlying mechanisms and treatment options are discussed.