Get your Health question answered in 3 easy steps
A Doctor will be with you shortly
Ask a Doctor Now
191 Doctors are Online

MRI scan after epidural injection shows moderate to left neural foraminal narrowing. What does this mean?

User rating for this question
Very Good
Answered by

Internal Medicine Specialist
Practicing since : 2005
Answered : 507 Questions
Hello. I had a cervical epidural injection for neck pain and arm numbness and pain (all on the left side) 3 weeks ago. I was under under anesthesia for the procedure but did not notice any concerning pain upon waking. When I went home for recovery I had severe soreness, enough I could barely sleep. but it seemed to get better after three days. Six days after the injection I felt the injection site still looked like a hump on my back and that I was having severe occipital neuralgia up the back of my head. My neurologist gave me topamax and told me to visit with my pain management specialist that gave me the injection. I tried to get a hold of him for two days and could not get a phone call returned (since the day before I went to the neurologist). Because my pain increased and I developed the worst headache of my life, like something was sitting inside my skull and hurting the front of my face and the nerves on the back of my head have become so sensitive I cannot touch them without my head feeling like it is going to explode or is on fire from pressure and pain, I went to the hospital the Friday (I think day seven, maybe day 8) after the procedure. The ER Drs. thought it might be a spinal headache because of the pain locations, however, the headache did not, and does not, get immediately better when I am flat, and because it presented itself almost a week away from the injection it made the diagnosis unclear. The Emergency room surgeon talked to me and said even if it is a dural puncture that no one does cervical blood patches because they are too XXXXXXX They did a CT scan that only showed only a 10 mm sublenticular cyst, incidentally noted on the right side. They sent me home with pain meds and steroids and told me to come back if the pain worsens. I went again to the hospital on sunday night, day 10, due to increased pain at site of injection and increased feeling of pain and pressure in neck and head. Also, when I would lay flat on my back the pressure on the back of my head and/or injection site caused me to feel like my blood pressure around my head was terrible and my heart rate would rise suddenly or fall suddenly . I am unsure if this was due to stress or related to the cause of my pain. The ER doctor ordered an MRI. He said there was nothing that gave him an idea as to what exactly was causing the problem and suggested it was some sort complication from the injection but could not tell if it was just irritation or something else. I was sent home and told to contact my pain management Dr. I noticed there was a small difference in the MRI findings and I want to post the original MRI impressions and the post epidural injection MRI impression and ask that you explain the differences. The pain management Dr. said that the differences were really only in the wording from the different radiologists. There is a specific part that I am interested in. The reason I want to have this explained is because my pain management Dr. seemed very certain there was nothing he could do for me and my symptoms and then after asking him what direction I should take and if I should see a specialist he said he wanted to try a cervical blood patch in two days. He wants me to stay home and rest and drink caffeine and see if I improve. He said my symptoms represent some aspects of a spinal dural puncture headache but others do not. If I had no improvement in these two days he will go ahead with the blood patch in the thoracic region right below the original injection site. By the time I went in for this office visit I could only lay on my side for some relief. Eventually i made two more painful trip to the emergency room because I got no significant relief of pain and pressure in the head laying down. The pain specialist did a blood patch over a week ago and this relusted in more stiffness around my neck and spine and down my back and enough pressure I stayed in the hospital for two days. It feels like there is just a tight squeeze on my spine. The heaviness inside my head is not letting up. He now wants to do another blood patch in two days and I am scared the pressure will put me back in the hospital. Also, my neurologist suggested I get a myleogram to trace the leak, but the pain specislist says this is a bad idea because that proceedure could cause another leak. I am confused as to why it is three weeks and the leak is not healing on its own or with the last blood patch. I also dont understand why I still feel pain and pressure while lauing flat. Can you explain what might be the reason for these? Also, i have been having severe night sweats. Should i be worried about infection or other complications? The mri looks like there is a bone spur pressing on my thecal sac near the location of the injection. I am concerned that the bone sour is actually protruding a but into the sac abd keeping the leak from healing. Is this possible? Why wont the mri show the exact site of the leak? Might it be something other than a leak abd whqt test should my dr be doing to rule tgese out or confirm? Should he be preforming this cervical blood patch without the consult of experienced surgeons about alternative diagnosis or risks considering he is uncertain as to the diagnosis? What would you do if it was you or your loved one? Please think carefully and let me know your advice. This is so important to me and I need a bit of direction as to what I need to be asking and demanding for and what possibilities there are I may not be aware of. Thank you for any help. A quick reply is needed. The MRI before and after impressions are posted below. 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.
Posted Sat, 15 Jun 2013 in Medicines and Side Effects
Answered by Dr. Omer 3 days later

I am Dr.Omer and I went through the details and I shall try to help with your medical puzzle.

You told that you had pain / numbness on the left side of body (arms?) and you underwent cervical epidural injection because of the spur that was pressing against the thecal sac. Now after 6 days of injection you had severe pain of your life - occipital, frontal in location with muscle stiffness of neck and back, with some relief in pain while lying on side , but not lying straightly , aggravated by movement? , walking? , sitting?.

Based on this description, I think the following are your plausible causes:

1. Post traumatic lumbar puncture headache(PTLPH)
2. Low spinal fluid headache
3.Postural tachycardia syndrome(POTs)

PTLPH as the name indicates is due to the cervical injection they gave you. It starts from 4-8 post injection day and continues for 2 week / month or even rarely years; again the pain seems to be maximum while in upright position or any position but can be relieved by lying on one side

Low spinal fluid headache is actually an overlapping disease with PTLPH. Here the pain is felt in occipital / frontal areas. It is more common seen in young females. The headache can start any time even after epidural injection, sweating , fast and slow heart rates

It is not necessary for the patients with PTLPH and low spinal fluid headache patients to have less pain on lying down , some have less pain on standing , and some have less pain when lying on side

Postural Tachycardia syndrome causes the headache on any posture , with variable heart rates , blood pressure , sweating, etc. This is also more common in female and can be triggered by epidural (traumatic ) injection.

Both the MRIreports show almost same reports

PTLPH and low spinal fluid headache are best treated by 2-6 times of epidural patches - one is seldom enough (10-20cc of your blood). Though your leakage is less, most patients are treated with more than 1 epidural patches

Epidural patches are not life threatening in any way , but they do have some complications like muscle stiffness and leg paresthesias.

Other treatments include fibrin glue injection at leakage point ( but less effective than epidural patch)

MRI with gadolium myelogram is the investigation of choice for PTLPH and low spinal fluid headache. it is safe as gadolium is safe. Myelogram was XXXXXXX before the invention of gadolium; so don't be worried.

Your pain doctor is going right , you need caffeine with lots of fluids and get a second epidural patch with a difference of >5 days from first injection

The best plan of action will be to get the MRI/CT myelogram and then go for second epidural patch at the specific leak point with more than 30 ml of your blood. Don’t worry the new leakage point of the needle is completely closed by the blood we give.

I hope this explains your query in detail. Let me know if you need clarifications.

Wishing you a speedy recovery

Take care
Above answer was peer-reviewed by
Share on Facebook
Share on Twitter
Share on Google+
Question is related to
Medical Procedures
Medical Topics

The user accepted the expert's answer

Ask an Internal Med Specialist

© Ebix, Inc. All Rights Reserved.
All the information, content and live chat provided on the site is intended to be for informational purposes only, and not a substitute for professional or medical advice. You should always speak with your doctor before you follow anything that you read on this website. Any health question asked on this site will be visible to the people who browse this site. Hence, the user assumes the responsibility not to divulge any personally identifiable information in the question. Use of this site is subject to our Terms & Conditions
Already Rated.
Your rating:

Ask a Doctor