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Cervical Meningomyelitis After Lumbar Epidural Steroid Injection.

Lee Y, Kim JS, Kim JY - Ann Rehabil Med (2015)

Bottom Line: Three days later, the weakness progressed to both upper extremities.C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord.Removal of the epidural abscess was performed, but there was no neurological improvement.

View Article: PubMed Central - PubMed

Affiliation: Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea.

ABSTRACT
Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.

No MeSH data available.


Related in: MedlinePlus

C-spine magnetic resonance imaging data. (A) T2 sagittal view showing signal change and swelling from medulla oblongata to upper thoracic cord. (B) T1 sagittal view showing leptomeningeal enhancement of medulla oblongata and cervical cord (arrow, epidural fluid collection at upper cervical area).
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Figure 2: C-spine magnetic resonance imaging data. (A) T2 sagittal view showing signal change and swelling from medulla oblongata to upper thoracic cord. (B) T1 sagittal view showing leptomeningeal enhancement of medulla oblongata and cervical cord (arrow, epidural fluid collection at upper cervical area).

Mentions: A 60-year-old male with a 5-year history of DM, 9-year history of hypertension, and 8-month history of angina presented with severe posterior neck pain and chest pain. Previously, the patient had persistent LBP with left thigh radiating pain for one month. At a local pain clinic, he was diagnosed as lumbar herniation of nucleus pulposus. He received two lumbar ESIs at the left L4 and L5 level with a 2-week interval. The injections produced no improvement. He visited another pain clinic 3 days later and received a lumbar ESI at the same level. A few hours after the injection, he complained of severe posterior neck and chest pain. He was transferred to our hospital the next day. The patient first received an electrocardiogram (ECG) and cardiac enzyme study due to the chest pain. ECG showed regular sinus rhythm and cardiac enzyme studies were all within normal limits (CK-MB 4.00 ng/mL, troponin-T <0.01 ng/mL). Fever developed a few hours after admission. Peripheral blood tests showed elevated white blood cell count of 20,430 (neutrophils 91.4%) and elevated C-reactive protein (24.14 mg/dL). Plasma glucose was also elevated (186 mg/dL). L-spine magnetic resonance imaging (MRI) revealed reticular infiltration at the left posterior epidural space of S1 level, suggesting hematoma in the left posterior epidural space at the L5 and S1 level (Fig. 1). Manual muscle test (MMT) revealed 5/5 muscle strength in all extremities. Methicillin-susceptible Staphylococcus aureus was isolated from blood culture. Under the diagnosis of lumbar epidural abscess, antibiotic treatment was started (clindamycin 600 mg IV, ceftriaxone 2 g IV). No improvement was noted, and a different antibiotic regimen was prescribed (vancomycin 2 g IV, Tazocin 4.5 g IV). The second regimen controlled the fever and laboratory findings indicated slight improvement. However, systemic elevation of plasma glucose remained, despite intensive insulin therapy. Ten days after hospitalization, the patient began to complain of bilateral lower extremity weakness and sensory disturbance. MMT showed 2/5 muscle strength in both lower extremities. Three days after the onset of motor weakness, the symptoms progressed from both lower extremities to include both upper extremities. MMT revealed 1/5 muscle strength in all extremities and the sensory examination showed hypoesthesia below the C4 dermatome. C-spine MRI revealed signal changes with swelling of the spinal cord at cervical cord and medulla oblongata with epidural fluid collection at the upper cervical area (Fig. 2A). Leptomeningeal enhancement of medulla oblongata and cervical cord was evident on the C-spine MRI (Fig. 2B). One week after the onset of motor weakness, the epidural abscess was removed with C1 and C2 laminectomy to decrease pressure of the upper cervical spine. Despite the surgery, no neurological improvement was observed. Two weeks after the surgery, a follow-up C-spine MRI revealed no interval change (Fig. 3). Two months after hospitalization, he was transferred to the department of rehabilitation medicine and received comprehensive rehabilitation therapy with the goal of improvement in motor power and stabilization of sitting balance.


Cervical Meningomyelitis After Lumbar Epidural Steroid Injection.

Lee Y, Kim JS, Kim JY - Ann Rehabil Med (2015)

C-spine magnetic resonance imaging data. (A) T2 sagittal view showing signal change and swelling from medulla oblongata to upper thoracic cord. (B) T1 sagittal view showing leptomeningeal enhancement of medulla oblongata and cervical cord (arrow, epidural fluid collection at upper cervical area).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
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getmorefigures.php?uid=PMC4496525&req=5

Figure 2: C-spine magnetic resonance imaging data. (A) T2 sagittal view showing signal change and swelling from medulla oblongata to upper thoracic cord. (B) T1 sagittal view showing leptomeningeal enhancement of medulla oblongata and cervical cord (arrow, epidural fluid collection at upper cervical area).
Mentions: A 60-year-old male with a 5-year history of DM, 9-year history of hypertension, and 8-month history of angina presented with severe posterior neck pain and chest pain. Previously, the patient had persistent LBP with left thigh radiating pain for one month. At a local pain clinic, he was diagnosed as lumbar herniation of nucleus pulposus. He received two lumbar ESIs at the left L4 and L5 level with a 2-week interval. The injections produced no improvement. He visited another pain clinic 3 days later and received a lumbar ESI at the same level. A few hours after the injection, he complained of severe posterior neck and chest pain. He was transferred to our hospital the next day. The patient first received an electrocardiogram (ECG) and cardiac enzyme study due to the chest pain. ECG showed regular sinus rhythm and cardiac enzyme studies were all within normal limits (CK-MB 4.00 ng/mL, troponin-T <0.01 ng/mL). Fever developed a few hours after admission. Peripheral blood tests showed elevated white blood cell count of 20,430 (neutrophils 91.4%) and elevated C-reactive protein (24.14 mg/dL). Plasma glucose was also elevated (186 mg/dL). L-spine magnetic resonance imaging (MRI) revealed reticular infiltration at the left posterior epidural space of S1 level, suggesting hematoma in the left posterior epidural space at the L5 and S1 level (Fig. 1). Manual muscle test (MMT) revealed 5/5 muscle strength in all extremities. Methicillin-susceptible Staphylococcus aureus was isolated from blood culture. Under the diagnosis of lumbar epidural abscess, antibiotic treatment was started (clindamycin 600 mg IV, ceftriaxone 2 g IV). No improvement was noted, and a different antibiotic regimen was prescribed (vancomycin 2 g IV, Tazocin 4.5 g IV). The second regimen controlled the fever and laboratory findings indicated slight improvement. However, systemic elevation of plasma glucose remained, despite intensive insulin therapy. Ten days after hospitalization, the patient began to complain of bilateral lower extremity weakness and sensory disturbance. MMT showed 2/5 muscle strength in both lower extremities. Three days after the onset of motor weakness, the symptoms progressed from both lower extremities to include both upper extremities. MMT revealed 1/5 muscle strength in all extremities and the sensory examination showed hypoesthesia below the C4 dermatome. C-spine MRI revealed signal changes with swelling of the spinal cord at cervical cord and medulla oblongata with epidural fluid collection at the upper cervical area (Fig. 2A). Leptomeningeal enhancement of medulla oblongata and cervical cord was evident on the C-spine MRI (Fig. 2B). One week after the onset of motor weakness, the epidural abscess was removed with C1 and C2 laminectomy to decrease pressure of the upper cervical spine. Despite the surgery, no neurological improvement was observed. Two weeks after the surgery, a follow-up C-spine MRI revealed no interval change (Fig. 3). Two months after hospitalization, he was transferred to the department of rehabilitation medicine and received comprehensive rehabilitation therapy with the goal of improvement in motor power and stabilization of sitting balance.

Bottom Line: Three days later, the weakness progressed to both upper extremities.C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord.Removal of the epidural abscess was performed, but there was no neurological improvement.

View Article: PubMed Central - PubMed

Affiliation: Department of Rehabilitation Medicine, St. Vincent's Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea.

ABSTRACT
Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.

No MeSH data available.


Related in: MedlinePlus