Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site: A case report.

RATIONALE

Transforaminal epidural steroid injection (TFESI) is a conservative method to treat back pain due to radiculopathy. However, epidural hematoma can occur after the procedure by various mechanisms, which can cause serious complications.

PATIENT CONCERNS

An 82-year-old man with spinal stenosis was treated with TFESI in the right intervertebral foramen at the L2-L3 level. The next morning, he experienced severe back pain and diffuse motor deficit.

DIAGNOSIS

Emergency magnetic resonance imaging revealed fluid collection in the posterior epidural space at the T11-L1 level with central-canal stenosis.

INTERVENTIONS

Emergency hematoma evacuation was performed to remove the epidural hematoma.

OUTCOMES

After the surgery, the back pain disappeared.

LESSONS

Epidural hematoma may occur due to causes other than direct needle injury after TFESI. Therefore, careful observation of the patient is necessary after the procedure.