Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections

BACKGROUND Various types of lumbar dural punctures may contribute to neurological injury. The etiologies of dural injury include; inadvertent dural punctures due to epidurals placed for labor anesthesia, epidural steroid injections (ESI/transforaminal TESI; approximately 9 million ESI performed in the US per year), deliberate placement of intradural pain devices, and spontaneous cerebrospinal fluid (CSF) fistulas. Resulting neurological complications may include; spinal headaches/intracranial hypotension, subdural hematomas, and 6th nerve cranial palsies. Furthermore, uniquely in the cervical spine, inadvertent cervical dural punctures attributed to cervcial ESI (CESI) may lead to intramedullary spinal cord injuries (e.g. resulting in monoparesis to quadriplegia) or spinal cord strokes due to intravascular/vertebral artery injections. METHODS/RESULTS In 8 studies, inadvertent lumbar dural punctures contributed to intracranial hypotension, subdural hematomas, and double vision/6th cranial nerve palsies. In 5 of the 6 studies, inadvertent dural punctures occurring during CESI were responsible for intramedullary spinal cord injuries, or direct intravascular/vertebral injections resulting in monoplegia/quadriplegia. CONCLUSIONS Inadvertent lumbar dural punctures led to multiple neurological complications including intracranial hypotension, subdural hematomas, and double vision/6th cranial nerve palsies. Uniquely, inadvertent cervical dural punctures solely due to CESI directly resulted in intramedullary spinal cord injuries or cord stroked and monoplegia/quadriplegia attributed to intravascular/vertebral artery injections. The potential neurological risks/complications/adverse events attributed to lumbar and cervical ESI must be taken into account before spine surgeons and others order these procedures.