1128 - Spinal Cord Infarction Following Transforaminal Epidural Steroid Injection with Particulate Steroid: A Case Report

Case Diagnosis: Spinal Cord Infarction

Case Description: Patient is a 72F with past medical history of UGIB, HTN, and L3-L5 laminectomy in 5/2025 who underwent L3-L4 left-sided transforaminal epidural steroid injection (TFESI) with a particulate steroid that resulted in a spinal cord infarction. Following the laminectomy, patient was without post op complications: did not have weakness, bowel/bladder incontinence, or saddle anesthesia and was ambulating with a cane. However, patient had persistent low back pain and a TFESI was recommended. Left-sided L3-L4 TFESI was performed with particulate steroid, and immediately following the procedure, patient developed bilateral lower extremity weakness, saddle anesthesia, and urinary retention. MRI lumbar/thoracic spine was significant for new mild enlargement and central hyperintensity within the distal spinal cord extending from T11 to the conus. Upon admission to acute rehab, physical exam was notable for bilateral lower extremity weakness and light-touch sensory deficits in T12 and L1 dermatomal distributions, resulting in a diagnosis of incomplete paraplegia.

Discussions: The use of particulate versus non-particulate steroid for TFESI is a contested topic given the presumed increased therapeutic duration of particulate steroid. However, several studies have demonstrated similar efficacies of particulate and non-particulate steroids in TFESIs for low-back pain. This case highlights the rare but devastating potential consequences of using particulate steroid for epidural steroid injections and emphasizes the importance of discussing risks and benefits of procedures with patients.

Conclusions: The use of particulate steroids for TFESI carries a rare but serious risk of spinal cord infarction that should be considered when deciding treatment options.