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 Table of Contents  
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 190-191

Horner syndrome: A hidden benign complication of cervical epidural injection

1 Department of Pain, Continental Hospitals, Hyderabad, Telangana, India
2 Department of Pain Medicine, Continental Hospitals, Hyderabad, Telangana, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Sudheer Dara
Flat Number 205, Bhanu Deluxe Homes, S. K. Road, Ameerpet, Hyderabad - 500 038, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_59_18

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Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects.

Keywords: Cervical epidural, Horner's syndrome, sympathetic pathway

How to cite this article:
Dara S, Chandra M, Varma R. Horner syndrome: A hidden benign complication of cervical epidural injection. Indian J Pain 2018;32:190-1

How to cite this URL:
Dara S, Chandra M, Varma R. Horner syndrome: A hidden benign complication of cervical epidural injection. Indian J Pain [serial online] 2018 [cited 2020 Feb 28];32:190-1. Available from: http://www.indianjpain.org/text.asp?2018/32/3/190/249108

  Introduction Top

Cervical epidural steroid injection can be done to alleviate pain in cases of cervical radicular pain in patients due to varied etiologies such as herniated disc. Many complications of cervical epidural injections are known. Horner's syndrome is a rarely occurring complication seen after epidural injections. Various literature have been described after lumbar epidural injections for painless labor, but not much is available following cervical epidural. Horner's syndrome presents as ptosis, miosis, enophthalmos, corneal hyperemia, facial flushing, and anhidrosis. It results due to interruption of the sympathetic nerve supply to the eye. It usually resolves spontaneously but may point to a major neurological deficit requiring further investigations.[1],[2]

  Case Report Top

A 40-year-female presented with neck pain radiating to the right upper limb for 6–7 years with tingling and numbness with visual analog scale of 6/10. There were no motor deficits, red flags, and systemic illness. Magnetic resonance imaging showed C5–C6, C6–C7 prolapsed intervertebral disc. Patient was advised cervical epidural injection as patient did not had pain relief with the Pharmacotherapy. The patient was counseled about the procedure, and written informed consent was taken. The patient was shifted to operation theater. Intravenous catheter 18 G, routine monitoring for noninvasive blood pressure, heart rate, oxygen saturation, and electrocardiogram were secured. The patient was put in a prone position with neck inflexion. C-arm was put in position. C6–C7 interlaminar epidural injection was done with 0.125% bupivacaine and 20-mg triamcinolone ruling out any intravascular injection. After the injection, the patient had decrease in pain scores. Thirty minutes after the procedure, the patient complained of drooping of the right eyelid. On examination, conjunctival hyperemia, ptosis, and miosis were seen in the right eye. The left eye was normal. The patient was stable. There were no other neurological symptoms. The patient was kept under observation. No treatment was required, and the symptoms resolved within 3–4 h without residual effect. The patient was discharged the next day.

  Discussion Top

Cervical epidural steroid injections should be done under image guidance to avoid major complications. Apart from known complications, rare complications such as Horner's syndrome can occur.

Horner's syndrome is a triad of ptosis, miosis, and anhidrosis. This condition is usually benign and does not cause vision problem but is an indicator of oculosympathetic pathway[3] disruption. Johann Friedrich Horner is credited to be the first to completely describe this syndrome in 1869 and that it occurs secondary to oculosympathetic paresis.[4]

The oculosympathetic pathway starts in the brain with first-order neurons located in the posterolateral hypothalamus. Then, sympathetic fibers pass through the ciliospinal center of Budge in the gray column of the spinal cord at C8–T1. Second-order neurons are the preganglionic sympathetic neurons which exit from the ciliospinal center of Budge and travel in the cervical sympathetic chain through the brachial plexus and then in stellate ganglion and synapse at superior cervical ganglion.[5] The postganglionic sympathetic neurons (third order neurons) originate in the superior cervical ganglion and travel along the wall of internal carotid artery and continue on to the cavernous sinus. In the cavernous sinus they travel along with abducent nerve, then join the opthalmic branch of trigeminal nerve to enter in the orbit with nasocilliary branch. The sympathetic fibers in the nasociliary nerve divide into the two long ciliary nerves innervate the iris dilator muscle. Any injury or disruption of this sympathetic pathway anywhere can lead to Horner's syndrome. Horner's syndrome occurring due to pharmacological disruption of the sympathetic preganglionic B-fibers is at the level of second-order neurons in the region of the C8–T2 roots innervating the eyes and face. Since these fibers are very small, they are sensitive to very small concentration of local anesthesia.[6] It is usually benign and does not cause significant vision problem, but it is an indicator of interruption of oculosympathetic pathway. The Horner's syndrome is usually transient with an average onset of 25 min and a mean duration of 215 min until spontaneous resolution.[7]

Many literature have reported the incidences of Horner's syndrome with local anesthesia used for different types of blocks.[8],[9],[10] Not many theories exist for the path physiology of Horner's syndrome except for the cephalic spread of the drug interrupting the preganglionic fibers.

In our case, the occurrence of Horner's syndrome following cervical epidural injection is a downward spread of the drug to block the preganglionic fibers in the spinal cord at C8–T1 level.

  Conclusion Top

This case reports a rare complication of cervical interlaminar epidural injection which though did not cause significant harm to the patient signifies the need for precision and careful monitoring of the patient. Horner's syndrome is usually self-limiting and therefore should be investigated if does not resolve spontaneously in few hours.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Thompson HS. The pupil. Curr Neuroophthalmol 1989;2:213-20.  Back to cited text no. 1
Safran MJ, Greenwald MJ, Rice HC, Polin KS. Cervical spine dislocation presenting as an isolated Horner's syndrome. Arch Ophthalmol 1990;108:327-8.  Back to cited text no. 2
Martin TJ. Horner syndrome: A clinical review. ACS Chem Neurosci 2018;9:177-86.  Back to cited text no. 3
Horner JF. On a form of ptosis. Klin Monbl Augenheilkd 1969;7:193-8.  Back to cited text no. 4
Kanagalingam S, Miller NR. Horner syndrome: Clinical perspectives. Eye Brain 2015;7:35-46.  Back to cited text no. 5
Kong X, Alston TA. Horner Syndrome after lumbar epidural analgesia in a patient with Ehlers Danlos syndrome. Open Anesth J 2018;12: 2589-6458.  Back to cited text no. 6
Lynch JH, Keneally RJ, Hustead TR. Horner's syndrome and trigeminal nerve palsy following epidural analgesia for labor. J Am Board Fam Med 2006;19:521-3.  Back to cited text no. 7
Jadon A. Horner's syndrome and weakness of upper limb after epidural anaesthesia for caesarean section. Indian J Anaesth 2014;58:464-6.  Back to cited text no. 8
[PUBMED]  [Full text]  
Sharma R, Chatterjee J, Edmonds K. Horner's syndrome with epidural anaesthesia. BMJ Case Rep 2010;2010. pii: bcr0120102698.  Back to cited text no. 9
Chakravarthy M, Prashant A, Mayur R. A case of unilateral ptosis following epidural anesthesia for cesarean section. J Obstet Anaesth Crit Care 2014;4:48-9.  Back to cited text no. 10
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