Chemical Meningitis Following an Epidural Steroid Injection Scott Stevens, MD; Ryan Keneally, MD; Sunil Hari, MD Department of Anesthesiology, Walter Reed National Military Medical Center; Bethesda, MD Uniformed Services University of the Health Sciences; Bethesda, MD Case Description 48 year old man with chronic low back pain and left leg radiculitis presents for epidural steroid injection. Previous ESI’s had yielded relief. Patient received an interlaminar ESI at L5-S1 using a 20- gauge Tuohy needle and loss of resistance technique paired with fluoroscopic guidance. An inadvertent dural puncture was noted, the needle was withdrawn, and then reinserted into the epidural space at the same level. Placement was confirmed by radio-opaque contrast injected under fluoroscopy [figures 1 & 2]. 80mg of methylprednisolone was injected into the space. Four hours later, the patient presented to the ED with complaints of headache, neck pain, fever, and pain radiating to both legs. He also reported tenderness to palpation at the injection site. MRI [looking for epidural hematoma or early abscess formation] was negative. Serum WBC count was 12,800 cells/L. Patient started on empiric antibiotics [2g ceftriaxone and 1g vancomycin], admitted to the hospital for further workup. LP revealed a WBC count of 5,369 cells/L [92% polymorphonuclear leukocytes], elevated protein [89 mg/dL] and decreased glucose [50 mg/dL]. After 3 days with negative cultures and clinical improvement, antibiotics were stopped. His headache and fever had resolved, and he reported improvement in his lumbar back pain and radicular symptoms. Discussion Postoperative chemical meningitis is rare, but found in literature back to 1925. Pathogenesis unknown, could be due to approach, instrumentation or the material being injected. Literature shows preference for transforaminal approach for efficacy, and suggests that interlaminar approach has largest risk of dural puncture. We suggest considering transforaminal or caudal approach for patients with history of dural puncture. Literature favors use of particulate steroids for efficacy, but favors nonparticulates in terms of risk profile. Discussion with patients to inform of the risk with different approaches and different steroids. Ultimately, this comes down to patient and clinician preference based on the available data and comfort level. Introduction Rare case of chemical [or aseptic] meningitis following outpatient epidural steroid injection for chronic low back pain Signs/symptoms indistinguishable from infectious meningitis We describe the diagnostic and treatment approach to this condition, as well as the factors potentially leading to this rare complication Imaging * * * References Zarrouk V, Vassor I, Bert F, Bouccara D, Kalamardes M, Bendersky N, Redondo A, Sterkers O, Fantin B. Evaluation of the management of postoperative aseptic meningitis. Clin Infect Dis 2007;44:1555-1559 Javed F, Grosu HB, Minkin R. Chemical meningitis following epidural anesthesia with bupivacaine: case report and review of literature. Chest 2009:136(4):36-37 Lee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection in lumbosacral herniated disk and spinal stenosis. J Back Musculoskeletal Rehabil 2009;22(2):83-89 Gharibo CG, Varlotta GP, Rhame EE, Liu EC, Bendo JA, Perloff MD. Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician 2011;14(6):499-511 Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell J. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med 2013:38(3):175-200 Park CH, Lee SH, Kim BI. Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. Pain Med 2010; 11:1654–1658 Figure 1. AP view Figure 2. Lateral view Contact information: CPT Scott Stevens, MD, scott.a.stevens94.mil@mail.mil. The views expressed in this poster are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the United States Government