Rationale: While epidural steroid injections (ESI) are a routine component of lumbar disc herniation management, the procedure carries inherent risks. Certain clinical presentations may signal an elevated risk for catastrophic complications, such as cauda equina syndrome. This report examines the significance of severe positional pain as a pre-procedural warning sign. Patient concerns: We present the case of a 65-year-old male who exhibited a critical physical sign: severe low back pain prohibiting a supine position. Despite this red flag, an interlaminar ESI was administered at the L2–3 level without prior definitive magnetic resonance imaging (MRI) evaluation. Diagnoses: Following the procedure, the patient progressed to acute paraplegia. Emergency MRI identified a massive L2–3 disc extrusion with near-total spinal canal occlusion, confirming a diagnosis of cauda equina syndrome. Interventions: The patient underwent emergency surgical decompression. Prior to this, he had received the interlaminar ESI which preceded the neurological decline. Outcomes: At the 4-month postoperative follow-up, the patient demonstrated partial neurological recovery, regaining the ability to ambulate short distances with the aid of a walker. Lessons: The inability to assume a supine position due to pain should be regarded as a marker for severe spinal stenosis or a large disc herniation. Proceeding with ESI without advanced imaging in such contexts poses an unacceptable risk of precipitating permanent neurological deficit. Comprehensive imaging is mandatory; if pain prevents MRI acquisition, alternative diagnostic strategies must be prioritized over blind intervention.
Zhang et al. (Fri,) studied this question.