A Rare Case of Deep Venous Thrombosis and Pulmonary Embolism after a Transforaminal Epidural Steroid Injection: Case Report

Background: Transforaminal epidural steroid injection (TFESI) allows administration of steroids directly into the foramen around the affected spinal nerve to relieve radicular pain. Although TFESI is generally considered a safe, minimally invasive intervention, potential complications include epidural hematoma, nerve injury, intravascular injection, and thrombotic risk such as deep venous thrombosis (DVT) and pulmonary embolism (PE) when anticoagulation therapy is held prior to the procedure. However, there are no cases showing isolated thrombotic events after an epidural steroid injection in a patient without hypercoagulable risk factors. This case highlights an unusual event of DVT/PE in the days after TFESI in a patient not on anticoagulation or antiplatelet therapy for any indication. Case Description: Author reports a 72-year-old man who presented with severe worsening back and right radicular leg pain refractory to oral pain medication and affecting the capacity to perform activities of daily living (ADLs). MRI of the lumbar spine showed L5-S1 central and right disc protrusion with moderate right narrowing of the right lateral recess with disc material abutting the S1 nerve root. The patient underwent right L5-S1 TFESI which improved pain and function. Three days post-procedure, the patient drove four hours and developed an acute left lower extremity DVT and PE with right heart strain, in addition to the return of severe disabling back pain. Conclusion: This case underscores the rare but important possibility of thromboembolic events following TFESI. Although prolonged immobility, such as long-distance driving, is a risk factor and a possible confounding variable for developing DVT/PE, this is one of the first reported cases of DVT/PE developing after TFESI. This case underscores the importance of monitoring for rare post-operative events to further advance patient safety for these procedures.