1203 - Cervical Spinal Cord Injury and Persistent Neuropathic Pain Secondary to Iatrogenic Epidural Hematoma: a Case Report

Case Diagnosis: Incomplete cervical SCI with persistent neuropathic pain secondary to iatrogenic epidural hematoma.

Case Description: A 63-year-old male was transferred to a tertiary care center with complete loss of lower limb volitional motion following a C7-T1 interlaminar epidural steroid injection (ESI) earlier that day. He took 81 mg aspirin daily for primary prophylaxis. MRI demonstrated acute epidural hematoma from C6-T6, marked cord compression C7-T1, and active epidural bleeding. He underwent emergent C6-T3 posterior decompression and C5-T4 posterior fusion.

He was admitted to inpatient rehabilitation with C7 AIS impairment scale class D spinal cord injury (SCI) with neurogenic bowel and bladder. After fourteen days, he discharged home, ambulating without gait aid seven weeks post-injury. He performed self-intermittent catheterization for four months post-discharge. He developed lower limb neuropathic pain several months post-discharge. After advanced imaging, electrodiagnostic testing, and multiple diagnostic and therapeutic injections, pain was presumed to be secondary to incomplete cervical SCI. He continues to experience pain and is considering trial of spinal cord stimulator.

Discussions: Incidence of epidural hematoma after cervical ESI is unknown. Anatomic variability in radicular and segmental medullary arteries in addition to the presence of the internal vertebral venous plexus contributes to both hemorrhagic and ischemic complications of ESIs. Current recommendations are to hold aspirin for six days prior to cervical or thoracic interlaminar ESI. Proper technique, optimization of coagulation status, and patient education regarding adverse events are vital. While symptoms may resolve following decompression, neurogenic bowel or bladder, reduced mobility, paralysis, and neuropathic pain have been reported.

Conclusions: Iatrogenic epidural hematoma is a rare adverse event after cervical ESI that may result in incomplete SCI-related complications, including persistent neuropathic pain. This case emphasizes the importance of discussing risks and benefits and carefully considering anticoagulation status prior to what many may consider to be a “routine” procedure.