Spontaneous thoracic epidural hematoma: a case report and literature review

Anterior Cord Syndrome Due to Spontaneous Spinal Epidural Hematoma

Spontaneous spinal epidural hematoma (SSEH) represents a rare clinical entity with an indeterminate etiology. Timely diagnosis and intervention are imperative due to the significant risk of permanent neurological deficits in the absence of appropriate treatment. This case report presents an instance of SSEH with no clear etiology. The patient arrived at the emergency department with paraplegia, urinary and fecal incontinence, and loss of pain and temperature sensation. She reported that these symptoms began abruptly after sneezing. The patient denied any pertinent medical history or family history. The patient initially experienced epigastric pain, which progressed to paresthesia. Magnetic resonance imaging confirmed an epidural hematoma extending from T2 to T8, necessitating immediate neurosurgical intervention. Although the patient was expected to recover within 72 hours postoperation, her symptoms persisted. Based on her clinical presentation, a diagnosis of anterior cord syndrome secondary to SSEH was confirmed.

Spontaneous spinal epidural hematoma leading to acute paraplegia: a case report

BACKGROUND

Spontaneous spinal epidural hematoma is an infrequent yet potentially debilitating condition characterized by blood accumulation in the epidural space, with only 300 documented cases globally. Although the exact etiology of spontaneous spinal epidural hematoma remains poorly understood, theories suggest arteriovenous malformations, rupture of epidural vessels, or epidural veins as possible causes.

CASE PRESENTATION

This study presents a 58-year-old Malay woman patient from Singapore with well-controlled hypertension, hyperlipidemia, type II diabetes mellitus, and microscopic hematuria. Despite a prior cystoscopy revealing no abnormalities, she presented to the emergency department with sudden-onset back pain, weakness, and numbness in both lower limbs. Rapidly progressing symptoms prompted imaging, leading to the diagnosis of a spinal epidural hematoma from thoracic (T) 9 to lumbar (L) 1. Prompt decompressive surgery was performed, and the patient is currently undergoing postoperative rehabilitation for paralysis.

CONCLUSION

This case emphasizes the severity and life-altering consequences of spontaneous spinal epidural hematomas. Despite various proposed causative factors, a definitive consensus remains elusive in current literature. Consequently, maintaining a low threshold of suspicion for patients with similar presentations is crucial. The findings underscore the urgent need for swift evaluation and surgical intervention in cases of acute paraplegia.

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.

Treatment of spontaneous spinal epidural hematoma in children: analysis of 25 cases

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency, presenting as sudden onset of back pain and weakness of lower extremities. Many patients have no definite cause. Some cases of SSEH caused by vascular malformation have been reported. The treatment strategy remains controversial. This study aimed to analyze the causes of SSEH and proposed a treatment strategy according to clinical outcomes of patients at a single institution.

METHODS

A total of 25 cases of SSEH under 18 years of age treated between March 2004 and July 2021 were retrospectively analyzed.

RESULTS

The mean age of the first SSEH onset was 7.1 years. The most common location was cervicothorax. Nine patients suffered from multiple episodes. Twenty-three patients underwent spinal digital subtraction angiography (DSA), of which seven (30.4%) patients had positive findings: three cases had epidural artery venous fistula (AVF), two cases had epidural artery venous malformation (AVM), and two cases had abnormal concentration of contrast agent. Seventeen patients received surgery. Eleven patients (44%) were diagnosed as vascular malformation by either DSA or pathology. The follow-up rate was 80%, with 20 patients (80%) achieving satisfactory clinical outcome. Risk factors for poor clinical outcome included multiple episodes (p = 0.028) and higher Aminoff-Logue score (p = 0.005).

CONCLUSION

Spinal epidural vascular malformation is a significant cause of SSEH. Spinal DSA is necessary. Surgery should be recommended for patients with multiple episodes, positive findings on DSA, or severe neurological deficits. Conservation therapy can be considered for other patients, but long-time follow-up is necessary.

A Rare Presentation of Spontaneous Spinal Epidural Hematoma as Spinal Cord Compression and Complete Paraplegia: A Case Report and Review of the Literature

Spontaneous spinal epidural hematoma (SSEH) is a serious but infrequent cause of profound neurological compromise of acute onset. It is often an atraumatic occurrence, and in around half of the cases, no etiology is identified. However, several causes such as arteriovenous malformation in the spine, use of anticoagulants in various cardiovascular diseases, and spinal trauma have been incriminated for its development. Here we encountered a case of SSEH following unregulated use of anticoagulants after a mitral valve replacement surgery. The patient had complete paraplegia with bowel and bladder involvement. The case was treated with decompressive laminectomy with regularization of her coagulation profile. Although she presented late to the healthcare center for the treatment, she showed a remarkable neurological improvement with gaining power worth near independent ambulation after one year of follow-up.

Surgical treatment of a spontaneous spinal epidural hematoma under antithrombotic treatment of a multisystem inflammatory syndrome in children associated with SARS-COV-2

Multisystem inflammatory syndrome in children (MIS-C) is a novel syndrome of multisystemic inflammation affecting children. This case report documents an exceptional and severe complication of an epidural hematoma in a 3-year-old boy under the treatment of MIS-C. During the course of the disease, the patient suffered from a hypocoagulable state and an extensive multisegmental epidural hematoma in the cervical spinal canal. This led to severe anterior spinal cord compression and tetraparesis. Extensive emergency surgery had to be carried out to reverse rapid clinical deterioration.

Spinal epidural hematoma in a child with hemophilia A with high titer inhibitors and follow-up with prophylactic emicizumab: case report and literature review

Hemorrhage in the central nervous system is the most severe and debilitating manifestation affecting patients with hemophilia A. The spinal epidural space is the most unusual and clinically challenging site of central nervous system hemorrhage in hemophilia A. These patients often show insidious neurological signs and symptoms that delay diagnosis and treatment. We share our experience treating a 4-year-old male patient with severe hemophilia A and high titer inhibitors with a spontaneous spinal epidural hematoma. The patient presented initially with intense headache and neck pain. After blood tests and imaging studies, bypassing agent therapy with recombinant-activated factor VII was used until discharge; this was later replaced with emicizumab. After 18 months, the patient is without neurological sequelae and has not experienced subsequent bleeding episodes. We review the available literature and discuss the relevance of emicizumab compared with standard therapies in the context of spontaneous spinal epidural hematoma.

Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention

Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.

Spontaneous spinal epidural hematoma masquerading as atypical abdominal pain in a child: A case report

INTRODUCTION

There have been few case reports of abdominal pain as a symptom of spontaneous intraspinal hemorrhage. We herein describe a case involving a girl with paraplegia caused by spontaneous epidural hemorrhage in the thoracic spinal canal, characterized by abdominal pain.

PATIENT CONCERNS

An 8-year-old girl with sudden abdominal pain and back pain was misdiagnosed as having an abdominal disease until she had the symptom of paralysis.

DIAGNOSES

The patient was diagnosed with spontaneous intraspinal hemorrhage masquerading as atypical abdominal pain.

INTERVENTIONS

When the patient developed symptoms of lower extremity paralysis, thoracic magnetic resonance imaging was performed and epidural hemorrhage was found in the thoracic spinal canal. Surgical treatment was performed after the diagnosis was confirmed.

OUTCOMES

The patient could almost walk normally after 3 months. One year after surgery, the Frankel grade of spinal cord function was grade D. We continued to follow-up this patient.

CONCLUSION

The symptoms caused by intraspinal hemorrhage are mainly back pain with or without neurological dysfunction. However, sometimes atypical symptoms, such as abdominal and chest pain, can be identified in clinical settings. Emergency surgery is recommended as the treatment of choice for intraspinal hemorrhage with neurological dysfunction.

Technical note: Novel use of recombinant tissue plasminogen activator for the evacuation of an acute extensive spinal epidural haematoma in a patient with coagulopathy

Spontaneous extensive spinal epidural haematoma poses a unique challenge for the neurosurgeon. Performing extensive laminectomies to remove all of the compressive haematoma can destabilise the patient's spinal column, which may require fixation. This is further complicated in patients with significant coagulopathy. We present a novel use of recombinant tissue plasminogen activator (rt-PA) in a patient with therapeutic coagulopathy, presenting with myelopathy secondary to an acute extensive spinal epidural haematoma. To the best of our knowledge, this is the first case of acute multilevel spinal epidural haematoma that has been successfully evacuated via single level laminectomy and topically applied rt-PA.

Sudden Onset of Severe Cervical Pain in an Adolescent Girl: Case Report and Review of Literature

A previously healthy 13-year-old girl presented with a 9-day history of acute onset severe neck pain associated with limited range of movement. Medical evaluation at day 2 was suggestive of muscle contracture, and she was discharged home with diazepam, antiinflammatory agents, and rest; however, she returned because of progressive clinical worsening with left arm distal paresthesia and paralysis since day 3. There was no history of trauma or other systemic complaints, and her familial medical history was unremarkable.Physical examination revealed left cervical and paravertebral tenderness on palpation with severe limitation of cervical and trunk movements; neurologic examination revealed left forearm and hand weakness and paralysis (grade II/V) with thenarhypothenar atrophy. Laboratory studies including coagulation profile were normal. Magnetic resonance imaging revealed an epidural hematoma from C4-T1 without underlying cause apparent on magnetic resonance angiography. On day 12, she underwent C3-7 laminotomy with laminoplasty and complete drainage of the hematoma. After 5 months of follow-up, she displays no neurological deficits. The spontaneous spinal epidural hematoma is a rare neurosurgical emergency in children. It usually presents acutely with neurologic deficits, but the initial presentation may be atypical or insidious, delaying diagnosis and intervention. Definitive diagnosis is made by magnetic resonance imaging and implies a high index of suspicion. Surgical drainage of the hematoma is the mainstay of treatment with favorable prognosis even in cases with a delayed diagnosis.

Spontaneous Spinal Haemorrhage as a Complication of Oral Anticoagulant Therapy: A Case Report and Literature Review

Spinal cord haematoma, or haematomyelia, is a rare condition caused by several unusual disease processes. Traumatic events, such as spinal cord injury and surgery or procedures involving the spinal cord, are the most important causes of spinal cord haematoma. Rarely, it is associated with anticoagulation therapy. Irrespective of cause, spinal cord haematoma is considered a neurosurgical emergency and must be treated promptly in order to prevent neurological sequelae. The authors describe the case of a 69-year-old patient taking warfarin in the therapeutic range for a mechanic mitral valve, who developed chest pain with cervical and dorsal radiation, and experienced sudden paraparesis of the limbs. A CT of the spine confirmed haematomyelia. A high index of suspicion, prompt recognition and immediate intervention are essential to prevent major morbidity and mortality from intraspinal haemorrhage.

LEARNING POINTS

This article reports an unusual presentation of spontaneous spinal haematoma, imposing the careful elaboration of differential diagnoses, which is very important in internal medicine.The description of this low-incidence case allows the scientific community to assist in approaching patients with similar symptoms.The lack of studies about the etiology and treatment of spontaneous spinal haematoma underlines the need for further studies and research in the area in order to increase the scientific evidence on the approach of these patients.

Imaging features of atypical bleeds in young patients with hemophilia

Hemarthroses and muscle bleeds are well-known and well-documented complications in pediatric and young adult hemophilia patients. In contrast, deep bleeds in atypical locations can be a diagnostic challenge, since clinicians and radiologists are often unfamiliar with their clinical and radiological features. Some atypical bleeds, however, can be life-threatening or severely disabling, highlighting the need for prompt, accurate diagnosis. Rare bleeds include central nervous system bleeds (including intracranial and spinal hematomas), urogenital bleeds, intra-abdominal bleeds (mesenteric and gastrointestinal wall hematomas) and pseudo tumors in unusual locations like the sinonasal cavities. Because clinical assessment can be difficult, clinicians and radiologists should be aware of the possibility of these rare complications in their hemophilia patients, so that they can avoid unnecessary invasive diagnostic and surgical procedures and institute prompt, appropriate treatment. The purpose of this review is to illustrate the imaging features of bleeds that occur in rare locations in young (i.e., children and young adults) patients with hemophilia to make the reader more familiar with these conditions.

Cervicothoracic epidural hematoma in a toddler with miosis, ptosis, nonspecific symptoms, and no history of major trauma: case report

INTRODUCTION

Spinal epidural hematomas are uncommon in children. The diagnosis can be elusive as most cases present without a history of trauma, while symptoms can be atypical.

CASE REPORT

We encountered a 35-month-old male presenting with nonspecific symptoms and no history of trauma. He later developed unilateral miosis and ptosis; MRI discovered a subacute cervicothoracic epidural which was promptly evacuated. The patient made an excellent recovery.

COCLUSIONS

We emphasize the frequent absence of identifiable trauma and the importance of thorough imaging when this entity is suspected. Miosis and ptosis, likely representing a partial Horner syndrome, is an extremely rare presentation, this being one of the only reported cases.

Spontaneous Spinal Epidural Hematoma from Rivaroxaban

Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.

Coagulation Profile as a Risk Factor for 30-day Morbidity Following Cervical Laminectomy and Fusion

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

The aim of this study was to determine the ability of abnormal coagulation profile to predict adverse events following posterior cervical laminectomy and fusion (PCLF).

SUMMARY OF BACKGROUND DATA

PCLF is an increasingly common procedure used to treat a variety of traumatic and degenerative spinal conditions. Abnormal coagulation profile is associated with postoperative adverse events, including blood transfusion. There is a paucity of literature that specifically addresses the relationship between coagulation profile and complications following PCLF.

METHODS

ACS-NSQIP was utilized to identify patients undergoing PCLF between 2006 and 2013. A total of 3546 patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications.

RESULTS

Membership in the low-platelet cohort was an independent risk factor for myocardial infarction (Odds Ratio (OR) = 5.4 [1.0, 29.1], P = 0.049) and bleeding transfusion (OR = 2.0 [1.2, 3.4], P = 0.011). Membership in the high international normalized ratio group was an independent risk factor for pneumonia (OR = 6.3 [2.5, 16.1], P < 0.001), ventilation >48 hours (OR = 6.5 [2.3, 18.4], P < 0.001), organ space surgical site infection (OR = 11.1 [2.1, 57.3], P = 0.004), urinary tract infection (OR = 3.0 [1.2, 8.0], P = 0.024), bleeding transfusion (OR = 6.0 [3.4, 10.7], P < 0.001), sepsis (OR = 5.1 [1.6, 16.4], P = 0.006), and septic shock (OR = 6.8 [1.7, 27.4], P = 0.007). Membership in the bleeding disorders cohort was an independent predictor of unplanned intubation (OR = 3.2 [1.1, 9.5], P = 0.041), pneumonia (OR = 2.9 [1.2, 7.2], P = 0.023), ventilation >48 hours (OR = 4.8 [1.9, 12.4], P = 0.001), cerebrovascular accident/stroke with neurological deficit (OR = 24.8 [2.9, 210.6], P = 0.003), bleeding transfusion (OR = 2.1 [1.1, 4.1], P = 0.032), reoperation (OR = 3.6 [1.4, 9.3], P = 0.008), and sepsis (OR = 3.4 [1.1, 10.4], P = 0.031).

CONCLUSION

This is the first large study to document abnormal coagulation profile as an independent predictor of outcomes following PCLF. Abnormal coagulation profile represents a predictor of complications that can be medically mitigated, and is therefore a valuable parameter to assess preoperatively. Coagulation profile should continue to play a role in targeting patients for risk stratification, preoperative optimization, and quality improvement initiatives.

LEVEL OF EVIDENCE

3.

Coagulation Profile as a Risk Factor for 30-Day Morbidity and Mortality Following Posterior Lumbar Fusion

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify associations between abnormal coagulation profile and postoperative morbidity and mortality in patients undergoing posterior lumbar fusion (PLF).

SUMMARY OF BACKGROUND DATA

The literature suggests that abnormal coagulation profile is associated with postoperative complications, notably the need for blood transfusion. However, there is little research that directly addresses the influence of coagulation profile on postoperative complications following PLF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) was utilized to identify patients undergoing PLF between 2006 and 2013. Nine thousand two hundred ninety-five patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications.

RESULTS

Low platelet count was an independent risk factor for organ space surgical site infections (SSIs) [odds ratio (OR) = 6.0, P < 0.001], ventilation >48 hours (OR = 4.5, P = 0.002), Acute renal failure (OR = 5.8, P = 0.007), transfusion (OR = 1.6, P < 0.001), sepsis (OR = 2.2, P = 0.037), reoperation (OR = 2.5, P = 0.001), and death (OR = 3.7, P = 0.049). High partial thromboplastin time (PTT) was an independent risk factor for ventilation >48 hours (OR = 5.6, P = 0.002), cerebrovascular accident (CVA)/stroke with neurological deficit (OR = 5.1, P = 0.011), cardiac arrest (OR = 5.4, P = 0.030), transfusion (OR = 1.5, P = 0.020), and death (OR = 4.5, P = 0.050). High International Normalized Ration (INR) was an independent risk factor for pneumonia (OR = 8.7, P = 0.001), pulmonary embolism (OR = 5.6, P = 0.021), deep venous thrombosis/Thrombophlebitis (OR = 4.8, P = 0.011), septic shock (OR = 8.4, P = 0.048), and death (OR = 9.8, P = 0.034). Bleeding disorder was an independent risk factor for organ space SSI (OR = 5.4, P = 0.01), pneumonia (OR = 3.0, P = 0.023), and sepsis (OR = 4.4, P < 0.001).

CONCLUSION

Abnormal coagulation profile was an independent predictor of morbidity and mortality in patients undergoing PLF. As such, it should be considered in preoperative optimization and risk stratification.

Spontaneous spinal epidural hematoma: literature review

Review the current literature regarding spontaneous spinal epidural hematomas (SSEHs) and report on the known risk factors, evaluation, and treatment of this rare entity. A literature search was performed using PubMed and Ovid to identify articles pertaining to SSEHs. Due to the rarity of the pathologic entity, only scattered case reports and associated reviews are available. SSEHs are a rare yet potentially life-altering event. The underlying risk factors are poorly understood, and SSEHs present with minimal or no antecedent trauma. SSEHs warrant urgent surgical intervention given the associated risk of permanent neurologic sequelae. Given the potential for persistent neurologic deficits, physicians must entertain a clinical suspicion of SSEH when a patient presents with a history of back pain followed by neurologic deficits. Even without clear risk factors for hemorrhage, the appropriate evaluation to include advanced imaging studies should be obtained to allow for identification of this entity and urgent surgical management.

Why Cannot Suction Drains Prevent Postoperative Spinal Epidural Hematoma?

BACKGROUND

Postoperative spinal epidural hematoma (POSEH) is different from spontaneous or post-spinal procedure hematoma because of the application of suction drains. However, it appeared that suction drains were not effective for prevention of POSEH in previous studies. The purpose of this study was to test our hypothesis that POSEH can be caused by hypercoagulability.

METHODS

This was an experimental study. One hundred fifty milliliters of blood was donated from each of the 12 consecutive patients who underwent spine surgery and infused into 3 saline bags of 50 mL each. One of the 3 bags in each set contained 5,000 units of thrombin. All of them were connected to 120 ± 30 mmHg vacuum suctions: drainage was started 8 minutes after connection to the vacuum system for 12 normal blood bags (BV8) and 12 thrombin-containing blood bags (TBV8) and 15 minutes after connection for the remaining 12 normal blood bags (BV15). The amount of initial and remaining hematoma at 20 minutes, 120 minutes, and 24 hours after vacuum application were measured by their weight (g). The primary endpoint was the difference between BV8 and TBV8. The secondary end point was the difference between BV8 and BV15.

RESULTS

The remaining hematoma in TBV8 was significantly greater than that in BV8 at all measurement points: 46.3 ± 12.4 vs. 17.0 ± 1.3 (p = 0.000) at 20 minutes; 33.0 ± 8.2 vs. 16.3 ± 1.2 (p = 0.000) at 120 minutes; and 26.1 ± 4.0 vs. 15.8 ± 1.6 (p = 0.000) at 24 hours after vacuum application. The remaining hematoma of BV15 was significantly greater than that of BV8 at all measurement points: 30.0 ± 12.0 vs. 17.0 ± 1.3 (p = 0.002) at 20 minutes; 24.2 ± 7.6 vs. 16.3 ± 1.2 at 120 minutes (p = 0.002); and 22.2 ± 6.6 vs. 15.8 ± 1.6 (p = 0.004) at 24 hours after vacuum application.

CONCLUSIONS

With a suction drain in place, the amount of remaining hematoma could be affected by coagulability. Thrombin-containing local hemostatics and the length of time elapsed before the commencement of suction resulted in hypercoagulability, indicating these two factors could be causes of POSEH.

Spontaneous chronic epidural hematoma in the lumbar spine associated with Warfarin intake: a case report

INTRODUCTION

Spontaneous spinal epidural hematomas are rare. However, in patients on anticoagulant treatment the risk may increase. Symptomatically patients may present with radiculopathy and even progressive neurological deficits.

CASE DESCRIPTION

We present a case of a warfarin treated patient with left L5 radiculopathy. MRI was evaluated as showing a lumbar disc prolapse or synovial cyst at L4-L5 level. The patient was operated and an organized material was removed and analysed as a hematoma. No prolapsed disc or synovial cyst was found. The patient was neurologically restored following the operation.

DISCUSSION AND EVALUATION

This case illustrates how spontaneous epidural spinal hematomas can present with symptoms of radiculopathy and radiologically be misinterpreted as a protruding disc or cyst.

CONCLUSION

Warfarin treated patients may have an increased risk of spontaneous spinal epidural hematomas.

The Effect of Coagulopathies on Perioperative Complications and Clinical Outcomes in Patients Treated With Posterior Lumbar Fusions

STUDY DESIGN

A retrospective database review.

OBJECTIVE

The aim of this study was to compare complication rates following one to two-level lumbar spine surgery in patients with primary hypercoagulable states and coagulopathies.

SUMMARY OF BACKGROUND DATA

Both hypercoagulable states and coagulopathies are not uncommon conditions that have the potential to significantly alter perioperative patient management. However, there are few studies that document the added risk of medical complications following spine surgery in these patient populations.

METHODS

The PearlDiver database (2005-2012) was utilized to determine perioperative complication rates in patients with primary hypercoagulable states and coagulopathies who underwent primary one to two-level posterolateral lumbar spine fusion. Control cohorts without specific hematologic disorders were matched by demographics and comorbidities. Ninety-day complication rates were determined, along with revision rates at one and two years. When considering complication rate comparisons between matched cohorts, P < 0.005 was considered significant.

RESULTS

In total, 746 patients with coagulopathies and 2753 patients with primary hypercoagulable states were selected. Matched control cohorts contained 74,879 and 54,007 patients, respectively. Hypercoagulable patients had significantly increased rates of medical complications [odds ratio (OR) 1.4], infections (OR 1.6), and venous thromboembolisms (OR 9.0) during the three months following spine surgery and same-day transfusions (OR 1.2) when compared with matched controls (P < 0.001). Patients with von Willebrand disease or hemophilia had increased rates of three-month infections (OR 2.3) and transfusion (OR 2.0) when compared with a matched control group (P < 0.005). One- and two-year revisions rates were not significantly higher for either pathologic cohort when compared to matched controls.

CONCLUSION

Both primary hypercoagulable states and coagulopathies increase infection and transfusion rates following one to two-level lumbar spine surgery.

LEVEL OF EVIDENCE

3.