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Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery

An Animal Study

¹ Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213. E-mail address: gokubadejo{at}hotmail.com
² Division of Comparative Medicine (M.R.T.) and Departments of Pathology (R.E.S.), Radiology (A.S. and C.J.M.), Orthopaedic Surgery (R.B.M. and K.D.R.), and Anesthesiology (A.H.G.), Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for K.D. Riew: riewd{at}wudosis.wustl.edu
³ Department of Orthopaedic Surgery, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT 84108

Investigation performed at the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the Barnes-Jewish-Christian Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Methods: Eleven adult pigs underwent direct injection, under fluoroscopic guidance, into the vertebral artery while under general anesthesia. A particulate steroid (methylprednisolone) was injected into four animals (Group 1), whereas seven animals received a non-particulate steroid (dexamethasone in four animals [Group 2] and prednisolone in three [Group 3]). Following injection, the animals were assessed by direct observation of physical activity and with magnetic resonance imaging. After the animals were killed, brain and spinal cord material was retrieved, fixed in paraformaldehyde for one week, and then subjected to histopathologic analysis.

Results: All four animals in Group 1 failed to regain consciousness after the injection and required ventilatory support. The animals in Groups 2 and 3 recovered fully and demonstrated no evidence of neurologic injury. Magnetic resonance imaging revealed upper cervical cord and brain stem edema in Group 1, but not in Groups 2 and 3. Histologic analysis showed early evidence of hypoxic and ischemic damage—specifically, early eosinophilic neuronal necrosis, nuclear condensation, white-matter pallor, and extracellular edema—in Group 1 but not in Groups 2 and 3.

Conclusions: These data suggest that one etiology of neurologic complications following cervical nerve blocks may be inadvertent intravascular injection of particulate steroids, as all animals injected with methylprednisolone had neurologic deficits while none of the controls injected with non-particulate steroids were affected. To our knowledge, this study is the first to demonstrate that particulate steroids cause neurologic deficits and to suggest that use of non-particulate steroids might prevent such complications.

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