An 85 y.o. male walks into the the ED with a complaint of neck pain, he is s/p a cervical epidural injection three weeks earlier.

Our patient had atlantoaxial rotatory subluxation as Dr. Noelker points out. The inferior facet of C1 is displaced completely anterior to the L facet of C2.  The  right inferior facet of C1  is also displaced anteriorly. This resulted in severe spinal canal stenosis at the level of C1-2 with severe cord impingement and impingement on the R vertebral artery.  Our patient however, was neurologically intact.  He had an xray prior to his corticosteroid injections showing this was not present.

Did the steroid injections contribute in anyway to the problem?  It is known that steroids can  cause destruction of joints and ligaments by preventing the inflammation which is necessary for healing. This is why steroid injections are given with three week intervals between them.  Steroids also inactivate vitamin D, limit Ca absorption by the GI tract, and increase urinary excretion of calcium. This leads to a decreased uptake of Ca by the bone and ultimately weakness of the fibro-osseous junctions. In addition to delayed healing, the complications of  cervical steroid injections as found in the malpractice literature include:

Quadriplegia, respiratory arrest, cardiac arrest, dural puncture, vertebrobasilar stroke, epidural hematoma, and cervical cord infarct.

Quadriplegia which was permanent has been reported with an intravascular injection. Transient quadriplegia has been reported with injection into a cervical radicular artery.  In this report, the patient was quadriplegic for only 20 minutes .  The authors state although injecting a local anesthetic may have only a temporary effect on spinal cord function, particulate steroids may act as an embolus and cause permanent impairment.

Respiratory arrest can be transient if lidocaine causes a high cervical block, so most physicians who give the injections just numb the skin and give steroids alone after that to avoid respiratory arrest.

Causes of cardiac arrest have been reported including blockade of the sympathetics leading to a bradycardic arrest and involvement of the phrenic nerve leading to apnea.

Our patient had surgery and is doing well. It is not known whether the steriods had any role in his condition.  Thanks to Dr. Baumgartner for the case.

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Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004;5:202-5