Inadvertent Subdural Injection during Cervical Transforaminal Epidural Steroid Injection

Serious complications following cervical epidural steroid injection are rare. Subdural injection of local anesthetic and steroid represents a rare but potentially life threatening complication. A patient presented with left sided cervical pain radiating into the left upper extremity with motor deficit. MRI showed absent lordosis with a broad left paramedian disc-osteophyte complex impinging the spinal cord at C5-6. During C5-6 transforaminal epidural steroid injection contrast in AP fluoroscopic view demonstrated a subdural contrast pattern. The needle was withdrawn slightly and repositioned. Normal lateral epidural and nerve root contrast pattern was subsequently obtained and injection followed with immediate improvement in radicular symptoms. There were no postoperative complications on subsequent clinic follow-up. The subdural space is a potential space between the arachnoid and dura mater. As the subdural space is larger in the cervical region, there may be an elevated potential for inadvertent subdural injection. Needle placement in the cervical subdural space during transforaminal injection is uncommon. Failure to identify aberrant needle entry within the cervical subdural space may result in life threatening complications. We recommend initial injection of a limited volume of contrast agent to detect inadvertent subdural space placement.