Orthopedic Surgery Expert Opines on Nerve Injury Following Epidural Injection

This case involves a middle aged male who was undergoing treatment for pain and inflammation in his lower back. The man was placed under general anesthesia and given an epidural injection of steroids in his lower back. After awaking from anesthesia, the man’s left hand was constricted into a fist, which he was unable to open. Despite ongoing treatment, the patients symptoms have not improved more than a year after the initial injury, despite assurances that it would be a temporary issue.

Question(s) For Expert Witness

1. How frequently do you treat patients undergoing cervical epidural spinal injections?

2. What are some typical causes of claw hand? How should it be prevented?

Expert Witness Response E-119718

I perform approximately 30 cervical epidural spinal injections per month and see approximately 100 patients per month who are a future candidate or have previously undergone a cervical epidural spinal injection. Claw hand is most likely to be caused by an injury to the C8 or T1 nerve root or to the lower trunks of the brachial plexus in the context of a cervical epidural spinal injection. A focal spinal epidural hematoma could potentially cause this complication depending on the route of entry and specific technique during the procedure. Direct needle trauma or intra-neural injection would also be a source of such injury. Preventing such potential sources of complication requires that minimal sedation is used such that the patient is alert and can warn the interventionalist if a paresthesia or excessive pain occurs, which typically indicate nerve trespass or that the needle tip is dangerously close to a nerve. Fluoroscopic guidance must be used and the injection of a contrast agent under live fluoroscopic observation is necessary. If a transforaminal epidural approach is used, particulate steroid agents must be avoided to prevent embolic injury to neural tissues.