Had cervical epidural injection. Having soreness at the injection site. Suggest
1st MRI Before Cervical Epidural Injection:
Impression- 1. Uncovertabral arthropathy result in moderate to severe left foraminal stenosis at C5-C6 and mild to moderate left foraminal stensosis as C6-7.
2. No spinal stenosis
3. Focal t2 hyperintense nodules within the strap muscles are nonspecific. Consider ultrasound for further evaluation.
Impressions from MRI after the Injection, which is from the ER visit two days ago.
1. No evidence of epidural abscess
2. Posterior disk osteophyte complex at C5-6 with partial effacement of the anterior thecal sac and moderate to left neural foraminal narrowing.
Back to my question...or one of my questions....could the partial effacement of the anterior thecal sac be causing these terrible symptoms? Is there a notable risk that there could be more compression and damage to the thecal sac if I have the blood patch in the thoracic region? Please, do read through and be very thorough about all my questions. I know there are a lot, but I need each one to get attention and receive an answer please. Thank you so much. I really need any help I can get in this frightening and painful situation.
Thank you for posting this query.
I have gone through the details of your symptoms, MRI spine, CT scan brain and the complication you have developed following CESI (cervical epidural steroid injection) diligently. I understand your pain and have multiple unanswered questions. I shall proceed to provide my opinion which I hope can help you. Should you have any doubts/have unanswered questions, please write back to me.
Your MRI cervical spine is consistent with uncovertebral arthropathy resulting in moderate to severe left foraminal stenosis at C5-C6 and mild to moderate left foraminal stenosis as C6-7.
Uncovertebral joints are formed between uncinate processes below, and the uncus above. They are located in the cervical region of the vertebral column between C3 and C6. Two lips project upward from the superior surface of the vertebral body below, and one projects downward from the inferior surface of vertebral body above. They allow for flexion and extension and limit lateral flexion in the cervical spine. Arthropathy is a degenerative disease and in your case involving these joints
Repeat MRI cervical spine following CESI also reveals the same arthropathy of uncovertebral joints but in different radiology words. These means the major complication - which include Dural and epidural hematoma, epidural abscess, spinal cord rupture, infarction of spinal cord - following CESI has been ruled out.
Further compication following CESI depends upon the approaches (which you have not mentioned).
By now you would have known that CESI done by two approaches interlaminar and transforaminal approach. Complications reported with transforaminal cervical epidural steroid injections include neck pain, transient increased radicular pain, nausea, vasovagal reaction, dural puncture, non-specific headache, abscess, paralysis, and cord injury. And complications reported with interlaminar cervical epidural steroid injections include dural puncture, bloating, nausea and vomiting, vasovagal reaction, facial flushing, fever, nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, stiff neck, Cushing’s syndrome, transient paresthesias, hypotension, respiratory insufficiency, transient blindness, epidural transient lightheadedness, dyspepsia, fluid retention, transient global amnesia, vertebral artery injury, paralysis, cord infarction and cerebellar infarction. Lastly incidence of dural puncture with interlaminar CESI ranges from 0.25% to 2.00% and transforaminal CESI is 1.12%
With this back ground details, the following possibility need to be considered responsible for your headache
1) Spinal headache
2) Dural puncture
3) Arachnoiditis (steroids and lidocaine are injected during epidural steroid injection to give better symptomatic relief, This itself can cause inflammation of arachnoid membrane )
4) Chemical meningitis (mild tear in dura which cannot be picked by MRI, this cause blood to come in contact with arachnoid space and irritate producing similar complaints
5) Secondary bacterial infection( Even though strict aseptic precautions taken during CESI still there is risk for infection)
These (above) are the possible causes where your MRI cervical spine does not show any fresh lesion.
Therefore my suggestions for you in view of your unbearable pain and neuralgic symptoms are
1) Get hospitalized for observation, vitals monitoring, Neurological observation for meningeal signs , and deficits .Take bed rest and IV fluids for hydration. Coffee can be continued.
2) A short course intravenous steroids such as intravenous dexamethasone can be given to take care of arachnoiditis and chemical meningitis (if any)
3) Flupirtine maleate can be used to relieve painful symptoms.
4) Get your blood tested - blood count, ESR, blood culture and blood sugar. The test preferable should be done before starting steroids
5) If total leucocyte count is raised, you may require CSF penetrans antibiotics parenterally (ceftriaxone + Staphylococcal sensitive antibiotics) to take care of bacterial infection
The above regiment should take care of your symptoms by a week's time. Else blood dural patch can be considered. As such, the autologous blood does not "repair" the leak, but rather treats the symptoms. Discuss with your treating doctor/neurologist about this protocol of evaluation and treatment.
Finally - Is there a notable risk that there could be more compression and damage to the thecal sac if I have the blood patch in the thoracic region
Ans: Your query regarding further worsening of thecal sac after patch is not possible as indentation are at cervical disc level and patch is planned at thoracic level.
I apologize for the delayed and a lengthy response, but I hope this will helped. I will be glad to clarify your additional queries.
Dr Sandhya Manorenj
I wanted to give an update and ask another question. After going to the hospital again last night due to the fact I coukd not get my pain levels under control and also I had the feeling of terrible pressure in my neck and head (though I realize this may actually be lack of pressure if its spinak fluid leak). They were going to admit me to the hospital but the ER dr talked to my pain specialist dr and they agreed to get me to a surgical center for a cervical blood patch. I have had the patch done and this is the day after. I still felt a headache after I woke up from surgery but was sent home for rest and to lay flat for 48 hours. Most of my symptoms have eased as I type this. The headache is in the background. However, it is not gone. A general practitioner on this site said it may take two or three day to see the results...but I am wondering what the results mean exactly if the blood patch is meant to treat the symptoms, not correct and close the leakage. Are they hoping this will aid my body in repairing the leak and keep me at a tolerable pain level while it does this?
Also, because my Dr. felt a leak was very unlikely but did the proceedure and I have some improvement, would this make the diagnosis of a leak more likely? If after 48 hours of being on my back from this patch I get up and my headache returns to a high level does this indicate fsilure of blood patch or addition healing time? Or might it mean the diagnosis is wrong? Thank you for these additional answers. I am quite anxious to equip myself with as much information as I can before asking my dr when I talk to him about this. I think he is a kind man, but I ask a lot of questions...as can see.
As for your suggestions above (1-5), would you still say these are relevant given my improvement and would they become relevant again if when I start moving around in a day, my pqin levels return? Is there anything I should be watching for as indicators of complications from this proceedure? My doctor only said to make sure I am able to urinate or else go back to the hopital. Last, is there anything else you would be doing if you were in my position that I should be doing or watching for or asking? Again, thank you so much for your in depth reply. It has beena scary situation for me and communication of the possibilites.
Glad to hear from you that you have undergone blood patch today and you are symptomatically better except for the headache which becomes more on standing.
Since you are symptomatically better ,by next 48 hrs your headache should be disappearing. I feel that it has worked .You need to take precaution ,most important is absolute bed rest for next 48 hrs and have plenty of fluids.Keep your leg end raised.
The headache is due to low intracranial pressure due to CSF ooze hence symptoms are more on standing because of further lowering of intracranial pressure on standing as per gravity more leakage will be there.Hence bed rest will prevent further worsening of symptoms and also helps in healing of leak after blood patch.
Your query regarding blood patch, that it will relieve symptoms than closing the leak, initially blood patch will clot and prevent further leakage,this in turn prevents headache as already mentioned above (mechanism of headche).
You need to monitor for worsening headache on lying position,sphincter disturbance ( bowel,bladder), radicular pain in limbs,and any deficits in limbs.
In some cases it will take 1 week to recover, so take bed rest if symptoms are persisting on standing.
Get well soon.Hope for the best
Dr Sandhya Manorenj
Hi tech city Hyderabad
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