Abstract Details

Title Acute Paraparesis Following Epidural Steroid Injection in a Patient with Spinal Dural Arteriovenous Malformation: Case Report and Review of Literature

Topic Interventional Neurology

Presentation(s) P07 - (-)

Poster/Presentation
Number 256

Objective

Background BACKGROUND: To the author's knowledge, this is only the fifth reported case of this complication in the setting of a dural AV fistula.

Design/Methods DESIGN/METHODS: Patient initially presented with chronic low back to a Physical Medicine & Rehabilitation practice. An MRI of the lumbar spine revealed multilevel lumbar radiculopathy due to intervertebral disc protrusions. The patient received a fluoroscopy guided L2-3 interlaminar epidural injection of 12 mg (2 ml) of betamethasone suspension with 4 ml of 0.25% bupivacaine. About 4 hours after the procedure, he acutely developed paraparesis. He reported to the ER about 15 hours post procedure and was found to have only some distal movements of leg, a sensory level at T10 and urinary retention.

Results RESULTS: An MRI of the thoracic spine was remarkable for diffuse abnormal T2/FLAIR spinal cord signal from T4 vertebral level to the conus with extensive CSF flow voids consistent with a dural AV fistula. Over the next 24 hours, patient's weakness improved to antigravity strength in his legs. A spinal angiogram confirmed a spinal dural AV fistula being fed from a lateral sacral branch off the left internal iliac artery.

Conclusions CONCLUSIONS: All reported cases so far had a delayed onset of symptoms (3-24 hours) after the procedure. Clinically, this can be differentiated from cases of acute paraparesis due to intraprocedural spinal artery ischemia which has immediate onset of symptoms. One proposed mechanism is the increased CSF pressure resulting from volume of the injection contents, thus exacerbating pre-existing venous congestion from the fistula. Another mechanism may be accidental nicking of a radicular vein draining the fistula leading to a steal phenomenon.

Authors/Disclosures
Kartavya Sharma, MD (University of Texas Southwestern Medical Center) PRESENTER	Dr. Sharma has nothing to disclose.
Gregor K. Wenning, MD	No disclosure on file

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