title: Cervical spinal cord injection of epidural corticosteroids: comprehensive longitudinal study including multiparametric magnetic resonance imaging.
abstract: Despite widespread use, the efficacy of epidural corticosteroid injections (ESI) for osteoarthritis-associated neck or radicular pain remains uncertain, so even rare serious complications enter into discussions about use. However, various factors impede investigation and publication of serious adverse events. To that end, we developed new magnetic resonance imaging (MRI) techniques for spinal cord white matter quantification and used the best available physiological tests to characterize a cervical spinal cord lesion caused by inadvertent intramedullary injection of Depo-Medrol. A 29-year-old woman with mild cervical osteoarthritis had 2 years of headache and neck pain (concussion and whiplash) after 2 minor motor vehicle accidents. During C5-6 ESI, she developed new left-sided motor and sensory symptoms, and MRI demonstrated a new left dorsal spinal cord cavity. Mild left-sided motor and sensory symptoms have persisted for more than 2.5 years, during which time we performed serial neurological examinations, standard electrodiagnostics, somatosensory evoked potentials, and transcranial measurement of corticospinal central motor conduction time (CMCT). We used 3-Tesla MRI with a 32-channel coil developed for high-resolution cervical spinal cord structural imaging, diffusion tensor imaging (DTI), and magnetization transfer (MT). T(2)(∗)-weighted signal and DTI and MT metrics showed delayed spread of the lesion across 4 vertebral levels rostrally, consistent with Wallerian degeneration within the ascending left dorsal columns. However, only CMCT metrics detected objective correlates of her left hemiparesis and bilateral hyperreflexia. DTI and MT metrics may better distinguish between post-traumatic demyelination and axonal degeneration than conventional MRI. These tests should be considered to better characterize similar spinal cord injuries.
authors.affiliation: A.A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA Departments of Neurology and Neuropathology, Massachusetts General Hospital, Boston, Massachusetts, USA Department of Electrical Engineering, Ecole Polytechnique de Montreal, Montreal, Quebec, Canada.
authors.forename: Julien
authors.initials: J
authors.lastname: Cohen-Adad
authors.forename: Bradley
authors.initials: B
authors.lastname: Buchbinder
authors.forename: Anne Louise
authors.initials: AL
authors.lastname: Oaklander
mesh_terms: D000305:Adrenal Cortex Hormones / Q000009:adverse effects*; D000328:Adult; D056324:Diffusion Tensor Imaging / Q000379:methods*; D005260:Female; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects*; D008137:Longitudinal Studies; D019547:Neck Pain / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology; D013119:Spinal Cord Injuries / Q000139:chemically induced* / Q000473:pathology / Q000503:physiopathology
chemical_list: D000305:Adrenal Cortex Hormones