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.
Dr sandhya Manorenj
Hi tech city Hyderabad