Paper Title
SPINAL CORD INJURY AND POSTDURAL PUNCTURE HEADACHE AFTER CERVICAL EPIDURAL STEROID INJECTION

Abstract
Background - Cervical interlaminar epidural steroid injection (CIESI) is increasingly being used as an interventional treatment for pain originating from the cervical spine. However, during CIESI, serious neurological complications may occur because of direct nerve damage due to inappropriate needle placement. Case report: A 35-year-old woman with no specific medical history presented with posterior neck pain radiating in the left upper arm, and left C6 nerve impingement on cervical magnetic resonance imaging (MRI). She underwent CIESI under fluoroscopy using the left C5/6 interlaminar approach at another hospital. Immediately post-procedure, the patient experienced dizziness, decreased blood pressure, left upper arm motor weakness, and sensory loss. She visited our emergency department with a postdural puncture headache (PDPH) that worsened from the procedure. Cervical MRI performed after admission showed intramedullary T2 high signal intensity and cord swelling from the C4/5 to C6/7 levels; thus, a spinal cord injury was diagnosed. The patient's PDPH spontaneously improved after 48 h. However, despite conservative treatment, the decrease in abduction of the left fifth finger and loss of sensation in the back of the left hand persisted up to 6 months post-procedure. On follow-up MRI performed 6-months post-procedure, the T2 high signal intensity in the left central intramedullary region was decreased compared with that observed previously; however, cord swelling was still present. Furthermore, left C7/8 radiculopathy with acute denervation activity was confirmed on electromyography performed 6-months post-procedure. Conclusion: The use of fluoroscopy does not guarantee the prevention of spinal cord penetration during CIESI. Moreover, persistent neurological deficits may occur, particularly with intrathecal perforation or intrathecal drug administration during CIESI. Therefore, in accordance with the recommendations of the Multisociety Pain Workgroup, we recommend performing CIESI at the C6/7 or C7/T1 level, where the epidural space is relatively large, rather than at the C5/6 or higher level. Keywords - This study was approved by the institutional review board of Korea University Medical Center, Guro Hospital, Seoul, Republic of Korea (2022GR0107) on February 16, 2022.