Rationale: We report a case of a 61-year-old patient who developed complex regional pain syndrome (CRPS) type II after a cervical transforaminal epidural steroid injection (CTESI).
Patient concerns: The patient developed sudden-onset severe pain and swelling of his upper right limb after a cervical transforaminal epidural injection.
Diagnoses: On physical examination, the patient's symptoms and signs corresponded to the Budapest criteria for CRPS. Cervical magnetic resonance imaging and laboratory tests were performed to rule out other causes. An electrodiagnostic study revealed right C6/7 radiculopathies. A three-phase bone scan showed increased uptake in the right wrist in all phases. Thus, he was diagnosed with CRPS type II due to a cervical nerve root injury caused by the transforaminal epidural injection.
Interventions: He received oral methylprednisolone and gabapentin, and underwent physical therapy for 9 days.
Outcomes: The pain and swelling of his right upper limb disappeared and he returned to his previous functional activities.
Lessons: CRPS type II due to cervical root injury is rare but can develop during CTESI. Early comprehensive physical therapy and oral medications might result in good outcomes.