Neurological deficits after epidural steroid injection: Time course, differential diagnoses, management, and prognosis suggested by review of case reports

Background. Neurological deficits after epidural steroid injection (ESI) are rare but occur despite meticulous technique. Some neurologic deficits reverse spontaneously, others reverse only with timely interventions, and some are permanent. Etiologies vary. Objectives. Assess the immediate diagnostic and treatment steps to undertake when a patient experiences a severe neurologic deficit so that the best neurologic recovery can be obtained. Design. The literature was systematically reviewed for case reports and case series describing neurologic deficit after ESI. Outcome Measures. From these reports, the mechanism, temporal onset, permanence or reversibility of the deficit, and assessment and management were recorded and analyzed. Results. Thirty-three cases of neurological deficits were identified: 19 permanent deficits and 14 reversible. Infarction was significantly associated with permanent deficits (P <= 0.008) and presented just after injection (P <= 0.03), compared with "noninfarct" groups. Temporal onset of differential diagnoses (subdural and intrathecal injection, hematoma, and vascular punctures) overlap. When deficits did not resolve consistent with inadvertent subdural/intrathecal injection, timely initial magnetic resonance imaging (MRI) should be carried out to diagnose mass lesions, which have an optimal 8-hour window for effective surgical intervention. Mass lesions have an excellent prognosis for recovery (83%) compared with infarctions (9%) (P <= 0.005). Conclusions. Faced with deficits after ESI that do not resolve, the physician will need access to MRI, or similar radiographic studies, and subsequent neurosurgical consultation and facilities if MRI results indicate a decompressible lesion. Respiratory insufficiency with quadriplegia and loss of consciousness can occur, and in the worst of scenarios, the physician would also need the capability to ventilate the patient.