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Rapid spontaneous recovery after development of a spinal epidural hematoma: a case report. Am J Emerg Med 2013; 32:291.e1-3. [PMID: 24238481 DOI: 10.1016/j.ajem.2013.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/06/2013] [Accepted: 10/06/2013] [Indexed: 11/22/2022] Open
Abstract
Spontaneous spinal epidural hematoma is a very rare clinical emergency. A permanent neurological deficit or even death may result if diagnosis and treatment are delayed. Many cases can be diagnosed upon detailed neurological examination and magnetic resonance (MR) imaging. Usually, surgery is required, but rarely, the condition may improve spontaneously. A 46-year-old male patient was admitted to our emergency department because of rapidly evolving severe paraplegia following development of sudden-onset neck pain. Spinal MR imaging detected an epidural hematoma compressing the spinal cord at the C5–T1 level. Clinical and radiological follow-up showed that the patient recovered spontaneously in 48 hours without any need for surgical treatment.
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Abstract
STUDY DESIGN Literature review. OBJECTIVE To identify case series that have been confused with cervical spondylotic myelopathy (CSM) to develop a comprehensive differential diagnosis. SUMMARY OF BACKGROUND DATA Myelopathy can be caused by a number of different etiologies. In those patients with CSM, the presentation is not always clear. Distinct radiographical and clinical characteristics, which are not always obvious, aid in arriving at the correct diagnosis. METHODS A PubMed search was done to identify reports written in English describing conditions that may present in a manner similar to CSM to differentiate them from CSM. Material from review articles and relevant textbooks was also considered. Information regarding the number of patients, the specific diagnosis presenting as myelopathy, the diagnostic findings, and the method(s) for distinguishing CSM from the initial diagnosis was abstracted from included articles. Salient features of the conditions were summarized. RESULTS A total of 35 citations (totaling 474 patients) that reported on diagnoses confused with CSM based on clinical presentation were included. All were case reports or small case series. The differential diagnoses were organized into 7 categories: congenital/anatomic, degenerative, neoplastic, inflammatory/autoimmune, idiopathic, circulatory, and metabolic. The primary conditions in the differential included amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia, and spinal tumors. CONCLUSION In the vast majority of cases, magnetic resonance imaging was an invaluable tool in determining the correct diagnosis. Electrodiagnostic studies, cerebrospinal fluid profile, unique symptomatology, and consideration of patient demographics can also aid in the diagnosis. Bilateral sensory complaints in the hands are suspicious for cervical cord pathology and MR imaging of the same should be done even if the electromyography/nerve conduction studies (NCS) suggest bilateral carpal tunnel syndrome. SUMMARY STATEMENTS: Physical exam findings are not always consistent with severity of disease in CSM; therefore, correlation to plain radiographs, MRI, and patient symptomatology is essential for arriving at the correct diagnosis. In some cases where these studies are still equivocal, use of other studies should be considered including electrodiagnostic studies as well as cerebrospinal fluid examination.
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Fedor M, Kim ES, Ding K, Muizelaar JP, Kim KD. Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature. KOREAN JOURNAL OF SPINE 2011; 8:272-82. [PMID: 26064145 PMCID: PMC4461739 DOI: 10.14245/kjs.2011.8.4.272] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 12/20/2011] [Accepted: 01/05/2012] [Indexed: 12/26/2022]
Abstract
Objectives The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits. Methods Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases. Results Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients. Conclusion We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.
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Affiliation(s)
- Mark Fedor
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Eric S Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kai Ding
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, USA
| | - J Paul Muizelaar
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
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Abstract
Spontaneous spinal epidural hematoma is an uncommon cause of cord compression in children, especially in infants. An 8-month-old infant was admitted to our hospital for a 40-day history of paraparesis in the lower extremities. This rapidly progressed to paraparesis with an inability to move the lower extremities. MRI of the cervicothoracic spine revealed an epidural mass with compression of the spinal cord. The infant underwent C7-T3 total laminectomies. The pathology and postoperative MRI confirmed spinal epidural hematoma from a vascular malformation. We present the case to highlight the significance of recognizing this chronic spontaneous spinal epidural hematoma and discuss the diagnosis, treatment options and prognosis.
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Affiliation(s)
- Shaoxiong Min
- Department of Orthopaedics, Zhu Jiang Hospital, Southern Medical University, Guangzhou, China
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Sarubbo S, Garofano F, Maida G, Fainardi E, Granieri E, Cavallo MA. Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1055-61. [PMID: 19859747 PMCID: PMC2899401 DOI: 10.1007/s00586-009-1175-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Indexed: 12/14/2022]
Abstract
Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.
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Affiliation(s)
- Silvio Sarubbo
- Division of Neurosurgery, Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy.
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Spontaneous spinal epidural hematoma: An urgent complication of adding clopidogrel to aspirin therapy. J Neurol Sci 2009; 285:254-6. [DOI: 10.1016/j.jns.2009.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/20/2022]
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Wang CC, Chang CH, Lin HJ, Lin KC, Kuo JR. Misdiagnosis of spontaneous cervical epidural haemorrhage. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 18 Suppl 2:210-2. [PMID: 19005691 DOI: 10.1007/s00586-008-0819-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Revised: 09/01/2008] [Accepted: 10/17/2008] [Indexed: 01/30/2023]
Abstract
Spontaneous spinal epidural haemorrhage is a rare condition. The initial clinical manifestations are variable. Nonetheless, most spinal cord lesions result in paraparesis or quadriparesis, but not hemi-paresis, if motor function is involved. We report on a 69-year-old man who presented initially with right-side limb weakness. He was initially misdiagnosed at emergency room with a cerebral stroke and treated inappropriately with heparin. One day after admission, correct diagnosis of acute spinal epidural haematoma was based on the repeated neurological examination and cervical magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. The pathogenesis of the haematoma could have been due to hypertension, increased abdominal pressure and anticoagulant therapy. We emphasize that patients with hemi-paresis on initial presentation could have an acute spinal epidural haemorrhage. We also draw the misdiagnosis to the attention of the reader because early recognition of spontaneous spinal epidural haematoma is very important for prompt and appropriate treatment to improve the overall prognosis.
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Affiliation(s)
- Che-Chuan Wang
- Department of Neurosurgery, Chi-Mei Medical Center, 901 Chung Hwa Road, Yung Kang City, Tainan, Taiwan
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Sobottke R, Horch C, Lohmann U, Meindl R, Muhr G. [The spontaneous spinal epidural haematoma]. Unfallchirurg 2006; 110:355-9. [PMID: 17123045 DOI: 10.1007/s00113-006-1194-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Spontaneous spinal epidural haematoma (SSEH) is a rare and serious condition. Four cases of SSEH are presented in this paper, three of which were in the cervical segment while one involved the entire spine. In two of these four cases the diagnosis was not made until late in the course, and persisting neurological deficits resulted; one case was diagnosed early and the neurological outcome was good; and in one the decompression achieved was inadequate, owing to intraoperative complications. Laminectomy was performed in all four cases for the purpose of decompression of the spinal cord but at different intervals after the onset of symptoms and with different neurological outcomes. The prognosis of SSEH depends heavily on the time that elapses between the onset of symptoms and the surgical treatment. The diagnostic procedure of choice is MRI.
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Affiliation(s)
- R Sobottke
- Klinik und Poliklinik für Orthopädie des Klinikums der Universität zu Köln, Josef-Stelzmann-Strasse 9, 50924 , Köln, Germany.
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Shin JJ, Kuh SU, Cho YE. Surgical management of spontaneous spinal epidural hematoma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:998-1004. [PMID: 16758110 PMCID: PMC3489451 DOI: 10.1007/s00586-005-0965-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Revised: 04/26/2005] [Accepted: 05/08/2005] [Indexed: 01/30/2023]
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity; its causative factors and the factors determining the outcome are still controversial. We reviewed our clinical experiences and analyzed the various factors related to the outcome for SSEH. We investigated 14 patients (11 men and 3 women) who underwent hematoma removal for SSEH from April 1998 to August 2004. We reviewed age, gender, hypertension, anticoagulant use and the preoperative neurological status using the Japanese Orthopaedics Association score by examining medical records, operative records, pathology reports, and radiographies, retrospectively. We were checking for factors such as the degree of cord compression owing to hematoma and the extent and location of the hematoma. Most patients included in the study were in their twenties or fifties. Four hematoma were located in the cervical region (29%), three were cervicothoracic (21%), four were thoracic (29%) and three were in the lumbar (21%) region and also 12 were located at the dorsal aspect of the spinal cord. In all cases, the neurological outcome improved after the surgical operation. There was a statistically significant difference between the incomplete and complete neurological injury for the preoperative status (P<0.05). The neurological outcome was good in those cases that had their hematoma removed within 24 h (P<0.05). The patients with incomplete neurological injury who had a surgical operation performed within 12 h had an excellent surgical outcome (P<0.01). Spontaneous spinal epidural hematoma was favorably treated by the means of a surgical operation. The favorable factors for SSEH operations were incomplete neurological injury at the time of the preoperative status and the short operative time interval.
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Affiliation(s)
- Jun-Jae Shin
- Neurosurgery, Yonsei University, Yongdong severance hospital, Kangnam-ku, Dokok-dong, 135-270 Seoul, Korea
| | - Sung-Uk Kuh
- Neurosurgery, Yonsei University, Yongdong severance hospital, Kangnam-ku, Dokok-dong, 135-270 Seoul, Korea
| | - Yong-Eun Cho
- Neurosurgery, Yonsei University, Yongdong severance hospital, Kangnam-ku, Dokok-dong, 135-270 Seoul, Korea
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Ravi D, Dwarakanath S, Satish R, Gopal S, Venkataramana NK. Spontaneous spinal extradural hematomas. J Clin Neurosci 2006; 13:269-72. [PMID: 16503490 DOI: 10.1016/j.jocn.2005.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Accepted: 03/22/2005] [Indexed: 11/20/2022]
Abstract
We review three patients who presented with acute spontaneous spinal extradural hematomas (SSEH). We discuss the presentation, imaging and management strategies. All three patients were adult women with thoracic SSEH. All had motor weakness prior to surgery. One patient recovered completely, one partially recovered and one did not recover. SSEH, although rare, should be considered in cases of acute onset paraparesis. The diagnostic modality of choice is magnetic resonance imaging. Favourable outcome is related to aetiology, interval between the ictus and presentation, and the severity of the neurological deficits. Emergent surgical drainage is the treatment of choice.
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Affiliation(s)
- D Ravi
- Department of Neurosurgery, Manipal Institute for Neurological Disorders, (MIND), Airport Road, Bangalore 560 017, India
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Villas C, Silva A, Alfonso M. Pure cervical radiculopathy due to spontaneous spinal epidural haematoma (SSEH): report of a case solved conservatively. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2005; 15 Suppl 5:569-73. [PMID: 16333682 PMCID: PMC1602183 DOI: 10.1007/s00586-005-0023-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2005] [Revised: 09/28/2005] [Accepted: 11/01/2005] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Spontaneous spinal epidural haematoma (SSEH) is widely recognised throughout the literature as a cause of myelopathy, radicular compression being very rarely reported. Surgical management is almost always recommended, especially in the cases of spinal cord compression. Conservative treatment is reported as a curiosity and only in the case of spontaneous improvement. This report presents the particular case of a 64-year-old patient undergoing anticoagulant therapy that had a cervical radiculopathy due to a SSEH confirmed by MRI. The patient improved spontaneously and symptoms were solved with unconventional conservative treatment and without stopping the anticoagulant therapy. CONCLUSIONS Spontaneous epidural haematoma must be kept in mind when patients undergoing anticoagulant therapy have a sudden onset of cervicobrachialgia. Even though most spinal surgeons advocate surgical treatment, a conservative approach may lead to a complete recovery and may be considered as a good option in the case of radicular involvement. Discontinuation of the anticoagulant therapy may not always be needed, especially when the clinical syndrome improves spontaneously.
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Affiliation(s)
- Carlos Villas
- Orthopaedic Surgery, University Clinic of Navarra, Pamplona, Navarra, Spain
| | - Alvaro Silva
- Orthopaedic Surgery, University Clinic of Navarra, Pamplona, Navarra, Spain
| | - Matías Alfonso
- Orthopaedic Surgery, University Clinic of Navarra, Pamplona, Navarra, Spain
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Kirwan R, Saigal G, Faingold R, O'Gorman A. Nontraumatic acute and subacute enhancing spinal epidural hematoma mimicking a tumor in a child. Pediatr Radiol 2004; 34:499-502. [PMID: 14747875 DOI: 10.1007/s00247-003-1129-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2003] [Revised: 11/16/2003] [Accepted: 11/24/2003] [Indexed: 10/26/2022]
Abstract
We describe a 10-year-old boy who presented with acute onset of neck pain and neurologic symptoms caused by a spinal epidural hematoma. An enhancing mass, which mimicked a tumor, was seen on MR imaging of the cervical spine. The uptake of gadolinium in the mass and the associated mass effect suggested a tumor etiology. Such spinal epidural hematomas are extremely rare in the pediatric population. Additionally, it is even more uncommon for spinal epidural hematomas to resemble tumors. It is important to consider this entity when an enhancing epidural mass is found on MRI in the setting of an acute presentation.
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