Spontaneous spinal epidural haematoma. Etiological considerations

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.

Safety of Erector Spinae Plane Blocks in Patients With Chest Wall Trauma on Venous Thromboembolism Prophylaxis

BACKGROUND

Current guidelines for severe rib fractures recommend neuraxial blockade in addition to multimodal pain therapies. While the guidelines for venous thromboembolism prevention recommend chemoprophylaxis, these medications must be held for neuraxial blockade placement. Erector spinae plane block (ESPB) is a newly described block for thoracic pain control. Advantages include its quick learning curve and potential for less bleeding complications. We describe the use of ESPB for rib fractures in patients on chemoprophylaxis. We hypothesize that ESPB can be performed in this patient population without holding chemoprophylaxis.

MATERIALS AND METHODS

This was a retrospective observational cohort study of a level 1 trauma center from 9/2016 to 12/2018. All patients with trauma with rib fractures undergoing neuraxial blockade or ESPB were included. Demographics, chemoprophylaxis and anticoagulation regimens, outcomes, and complications were collected.

RESULTS

Nine hundred sixty-four patients with rib fracture(s) were admitted. Of these, 73 had a pain management consult. Thirteen had epidural catheters and 25 had ESPBs placed. There was no difference in demographics, injury patterns, bleeding complications, or venous thromboembolism rates among the groups. Patients with ESPB were less likely to have a dose of chemoprophylaxis held because of placement of a catheter (25% versus 100%, P < 0.00001). Three patients with ESPB were on oral anticoagulation on admission, and two were able to continue their regimen during placement.

CONCLUSIONS

ESPB can be safely placed in patients on chemoprophylaxis. It should be considered over traditional blocks in patients with blunt chest wall trauma because of its technical ease and ability to be performed with chemoprophylaxis.

Spontaneous spinal epidural haematoma following intra-arterial catheter-directed thrombolysis: A case report

A 79-year-old Chinese gentleman presented with unilateral acute lower limb ischaemia and received intra-arterial catheter-directed thrombolysis, initially with good result and reversal of the ischaemia. However, he developed an extensive spontaneous spinal epidural haematoma within hours of the procedure and was left with permanent paraplegia after being deemed unsuitable for decompressive spinal surgery. This report serves as a reminder of the risk of severe complications of catheter-directed thrombolysis by describing this rare but devastating side-effect that occurred even despite early detection from onset of symptoms.

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.

Spontaneous thoracic epidural hematoma: a case report and literature review

Spinal epidural hematoma is a rare neurosurgical emergency in respect of motor and sensory loss. Identifiable reasons for spontaneous hemorrhage are vascular malformations and hemophilias. We presented a case of spontaneous epidural hematoma in an 18-year-old female patient who had motor and sensory deficits that had been present for 1 day. On MRI, there was spinal epidural hematoma posterior to the T2-T3 spinal cord. The hematoma was evacuated with T2 hemilaminectomy and T3 laminectomy. Patient recovered immediately after the surgery. Literature review depicted 112 pediatric cases (including the presented one) of spinal epidural hematoma. The female/male ratio is 1.1:2. Average age at presentation is 7.09 years. Clinical presentations include loss of strength, sensory disturbance, bowel and bladder disturbances, neck pain, back pain, leg pain, abdominal pain, meningismus, respiratory difficulty, irritability, gait instability, and torticollis. Most common spinal level was cervicothoracic spine. Time interval from symptom onset to clinical diagnosis varied from immediate to 18 months. Spinal epidural hematoma happened spontaneously in 71.8 % of the cases, and hemophilia was the leading disorder (58 %) in the cases with a definable disorder. Partial or complete recovery is possible after surgical interventions and factor supplementations.

Spontaneous epidural spinal haematoma in children caused by vascular malformations

PURPOSE

The occurrence of spinal epidural haematoma of 'spontaneous' origin in adults is a well-documented entity, though it is rare in children. In the literature to date, there are few cases of this kind of spontaneous haematoma proven to be due to an underlying vascular abnormality.

METHOD

Retrospective review of two cases of children under 15 years of age with spontaneous epidural spinal haematoma.

RESULTS

Underlying arteriovenous malformations were identified in both cases. Intra-operative photographs and histological sections of these anomalies are presented.

CONCLUSION

These are the first two such cases described with clinico-pathological correlation.

Spontaneous cervical epidural hematoma presenting as brown-sequard syndrome following repetitive korean traditional deep bows

Spontaneous cervical epidural hematoma (SCEH) is an uncommon cause of acute nontraumatic myelopathy. SCEH presenting as Brown-Sequard syndrome is extremely rare. A 65-year-old man had motor weakness in the left extremities right after his mother's funeral. He received thrombolytic therapy under the impression of acute cerebral infarction at a local hospital. However, motor weakness of the left extremities became aggravated without mental change. After being transferred to our hospital, he showed motor weakness in the left extremities with diminished pain sensation in the right extremities. Diagnosis of SCEH was made by cervical magnetic resonance imaging. He underwent left C3 to C5 hemilaminectomy with hematoma removal. It is important for physicians to be aware that SCEH can be considered as one of the differential diagnoses of hemiplegia, since early diagnosis and management can influence the neurological outcome. We think that increased venous pressure owing to repetitive Korean traditional deep bows may be the cause of SCEH in this case.

Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases

We report 2 cases of spontaneous spinal epidural haematoma after antiplatelet treatment. One patient was on ticlodipine therapy and the other was on aspirin and clopidogrel. Both diagnoses were made using magnetic resonance imaging. One patient underwent multilevel laminectomies and posterior spinal fusion within 24 hours of symptom onset and achieved complete neurological recovery. The other underwent unilateral hemilaminectomies 40 hours after symptom onset and did not show neurological improvement. A high index of suspicion is needed for patients presenting with severe lower back pain and rapid neurological deterioration, especially in those on antiplatelet therapy. Urgent spinal cord decompression and epidural haematoma cord evacuation may provide more favourable outcome.

Delayed traumatic spinal epidural hematoma with neurological deficits

To describe the mechanism that causes spinal epidural hematoma with neurologic deficit and review the literature. We report a case of a 62-year-old man with post-traumatic epidural hematoma in the cervicothoracic spine, who developed progressive neurological deficit which eventually resulted in complete paralysis below T1. During surgical evacuation significant spine compression due to an organizing hematoma was observed. After surgery, the patient's motor function improved and there was a complete recovery of the neurologic deficit after a rehabilitation program.

CONCLUSION

Epidural hematoma can happen after delayed traumatic event leading to a variable degree of neurologic damage.

Spontaneous resolution of a traumatic cervicothoracic epidural hematoma presenting with transient paraplegia: a case report

STUDY DESIGN

Case description.

OBJECTIVE

To clinically and radiographically describe a traumatic spinal epidural hematoma (TSEH) without adjacent spinal column fracture or soft tissue injury that completely resolved, without surgical intervention.

SUMMARY OF BACKGROUND DATA

Symptomatic TSEH is an infrequent condition after spinal trauma, accounting for 0.5% to 1.7% of cases. It can result in permanent neurologic deficits if not treated in a timely and appropriate manner.

METHODS

A 50-year-old man presented with progressive lower motor weakness and sensory change at 2 days after blunt trauma to the upper back area. Neurologic examination revealed paraplegia and hypesthesia below the T4 sensory dermatome. Magnetic resonance imaging for cervicothoracic spine showed a space-occupying lesion in the dorsal spinal epidural space from C7 to T5. The lesion was consistent with acute stage hematoma of the spinal epidural space.

RESULTS

The patient was prepared for decompression surgery. However, the patient's neurologic symptoms began to improve (grade 4/5) at 2 hours after onset of paraplegia. Surgical intervention was delayed, and the patient was treated conservatively with close neurologic monitoring. Three days after onset of symptoms, the patient's neurologic symptoms recovered completely. The follow-up magnetic resonance imaging at 12 days after the event showed complete resolution of the epidural hematoma.

CONCLUSION

An unpredictable extensive epidural hematoma can occur after blunt trauma of the cervicothoracic spine in patients at low risk for hemorrhage. This case illustrates that immediate surgical intervention may not always be necessary in certain patients with TSEH. Conservative management with careful observation may play a role as a management option for patients initially presenting with severe neurologic dysfunction if neurologic recovery is early and sustained.

Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation

Acute onset of hemiparesis is a common initial presentation of cerebral vascular accidents, but many differential diagnoses should be considered. Hemiparesis results from an upper motor neuron lesion above the midcervical spinal cord, and the absence of cranial nerve signs or facial palsy suggests a lesion in the high cervical spinal cord. Most spinal cord lesions, however, result in quadriparesis or paraparesis, but not hemiparesis. We present a rare case of acute spontaneous cervical spinal epidural hematoma, with initial presentation of right hemiparesis and mild neck pain.

Analysis of the risk factors for the development of post-operative spinal epidural haematoma

In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

Epidural haemorrhage of the cervical spinal cord: a post-mortem artefact?

Spinal epidural haemorrhage is a rare entity that occurs uncommonly in adults and rarely in children. It has a typical clinical presentation, although to date, the cause for the majority of cases remains unknown. We present a series of cases where epidural haemorrhage was identified at post-mortem, principly to the cervical cord, in cases outside the age range usually reported for clinical epidural haemorrhage, and with no underlying pathology to account for the finding. We present a hypothesis for a post-mortem cause for this finding and consider that, in the absence of any other identifiable causation, then this is a post-mortem occurrence similar to that of the Prinsloo-Gordon artefact of the soft tissues of the neck. This finding must be interpreted with care so as not to make the mistaken diagnosis of a nonaccidental head injury based on its finding, especially in the absence of intracranial, cranial nerve, optic nerve or eye pathologies.

Epidural hematoma after immobilization of a "hangman's" fracture: case report and review of the literature

BACKGROUND CONTEXT

Neurologic deterioration after immobilization of traumatic spondylolisthesis of the axis rarely occurs because of the decompressive nature of the injury itself and the large amount of space available for the cord in the upper cervical spine.

PURPOSE

To document neurologic deterioration after reduction (without the use of traction) and halo immobilization of a Type IIA traumatic spondylolisthesis of the axis (hangman's fracture) secondary to an epidural hematoma.

STUDY DESIGN/SETTING

Case report. PATIENT SAMPLE AND OUTCOME MEASURES: The patient population consisted of one patient; no outcome measures were used.

METHODS

The medical record and radiographic studies of a 27-year-old patient involved in a motor vehicle crash that resulted in a traumatic spondylolisthesis of the axis were retrospectively reviewed, and a review of the English literature was performed.

RESULTS

Upon evaluation, the patient was found to have, in addition to other injuries, a Type IIA hangman's fracture of the C2 vertebra, which was stabilized in a halo. Shortly thereafter, the patient developed a gradual progressive neurologic deficit. Magnetic resonance imaging revealed the presence of a large epidural hematoma with cord compression treated with posterior laminectomy and transdural decompression of an anterior hematoma. Postoperatively, the patient's neurologic examination improved and returned to normal within 6 months.

CONCLUSION

An epidural hematoma can occur after traumatic spondylolisthesis of the axis, but its symptoms may not present until after the spondylolisthesis is treated.

[Spinal manipulative therapy and cervical artery dissections]

Severe complications after cervical spine manipulation are rare. As experts for medical treatment errors, we received between July 2002 and February 2004 cases with serious complications in the central nervous system after manipulation. 5 vertebral artery dissections with subsequent brain infarction were registered. In all cases, the patients showed complete persisting remission of symptoms. In addition, a kinematic estimation model was developed to study the possible causes of vertebral artery damage. We were able to demonstrate that material extension is dependent on cervical rotation and the "free length" of the vertebral artery in the upper cervical spine.

Delayed traumatic spinal epidural hematoma with spontaneous resolution of symptoms

Post-traumatic spinal epidural hematomas are uncommon, usually requiring emergent neurosurgical evacuation. We present a symptomatic delayed post-traumatic epidural hematoma of the T-spine that resolved within hours of administration of high dose steroids. A 22-year-old man presented 10 days after sustaining blunt trauma during a motor vehicle crash. He developed signs of acute cord compression with loss of sensation and motor function in bilateral lower extremities with priapism. Magnetic resonance imaging demonstrated a spinal epidural hematoma with 50% canal stenosis at the T4 level. His symptoms improved 1 h after the administration of high dose steroids. All symptoms resolved completely while the patient was in the Emergency Department and he was treated conservatively by Neurosurgery with no further sequelae. Thoracic spinal epidural hematoma is an uncommon condition that may present in delayed fashion after trauma with significant neurologic compromise. If neurologic symptoms improve with initial steroid therapy, patients with this condition may be treated conservatively with steroids and observation.

Neurologic complications of sit-ups associated with the Valsalva maneuver: 2 case reports

We present 2 cases of potentially catastrophic neurologic consequences occurring in healthy individuals engaged in sit-up exercises. Two young healthy men were engaged in sit-ups when one developed a stroke and the other developed a spinal epidural hematoma. The Valsalva maneuver involved in the sit-up exercise can produce supraphysiologic increases in blood pressure, which can lead to vascular injury and serious neurologic consequences. Proper breathing should be encouraged and patients with known predisposing factors should avoid such exercises. Prompt recognition of neurologic signs and symptoms during exercise can be life saving. This is the first report of the neurologic complications of sit-ups.

Neurological complications in obstetric regional anaesthesia

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

Traumatic epidural hematoma of the cervical spine: magnetic resonance imaging diagnosis and spontaneous resolution: case report

OBJECTIVE AND IMPORTANCE

Demonstration of interest of medical treatment of cervical epidural hematomas.

CLINICAL PRESENTATION

A young patient developed cervical pain after experiencing cervical trauma. Computed tomography and magnetic resonance imaging demonstrated an epidural cervical hematoma. A spontaneous resolution of the clinical symptoms and the radiological abnormalities was observed.

CONCLUSION

Although surgical decompression is generally regarded as mandatory in selected patients with incomplete and nonprogressing deficits, conservative management may be possible.

Spontaneous spinal epidural hematoma in children

Spontaneous spinal epidural hematoma is rare in children. It is usually confined to the dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is rarer, with only two previous reports. The authors present three children, two with dorsal and one with ventral spinal epidural hematoma, and review the literature. No etiology of the hematoma was found in the authors' patients and there was no history of trauma. A review of 24 patients of children younger than 18 years of age reported in the literature and the authors' three patients revealed that the cervicothoracic region was the most common site of SSEH, the mode of onset was frequently subacute, and there was no male preponderance as has been reported in adults. We found that the initial symptoms were often nonspecific, leading to a delay in diagnosis, especially in younger children. Follow-up data revealed that 15 of the 27 patients recovered completely, 11 had residual neurologic deficits, and one patient died. Irritability and neck pain with restricted movements of the cervical spine in an afebrile child may be early signs of SSEH and often precede onset of neurologic deficits by several hours to days. These signs should alert the clinician to consider spinal epidural hematoma and the need for urgent magnetic resonance imaging (MRI) of the spine for early diagnosis and treatment to minimize morbidity.

Outcome after spontaneous spinal epidural hematoma in children: case report and review of the literature

OBJECTIVE

Spontaneous spinal epidural hematoma (SSEH) is an idiopathic accumulation of blood in the vertebral epidural space without identifiable predisposing factors. First reported in 1869, the clinical outcome in children younger than 18 years old has not been clearly delineated.

DESIGN

A comprehensive review of the English language literature revealed 26 patients younger than 18 years old with reported clinical outcomes. The 27th case is presented.

RESULTS

Complete neurologic recovery occurred in 14 of 27 (52%) patients, partial recovery in 12 of 27 (44%) patients, and death in 1 of 27 (4%) patients.

CONCLUSION

There is an overall good prognosis for neurologic recovery in children who experience SSEH.

The role of endoscopy in the treatment of acute traumatic anterior epidural hematoma of the cervical spine: case report

OBJECTIVE AND IMPORTANCE

Epidural hematoma (EDH) of the spine represents an uncommon neurosurgical disorder that sometimes requires emergent surgical decompressive therapy. Traumatic EDH of the cervical spine is exceedingly rare. The hematoma is usually located dorsally in the epidural space. We present one case of acute EDH located ventrally in the cervical spine. Special emphasis is placed on the role of spinal endoscopy in surgical treatment.

CLINICAL PRESENTATION

After a fall from a tree, a 69-year-old man with rapidly increasing tetraparesis was referred to our institution. Plain films of the cervical spine revealed nothing abnormal. The results of computed tomography were highly suspicious for EDH. A myelogram and a post-myelographic computed tomographic scan demonstrated the lesion and its extent craniocaudally.

INTERVENTION

Emergency decompressive surgery and removal of the hematoma were performed via an anterior approach. Control for total removal of the EDH was achieved using a flexible neuroendoscope providing visualization of the anterior epidural space from the foramen magnum to the T1 level. Surgery was accomplished by vertebral body replacement and anterior plating.

CONCLUSION

Spinal endoscopy seems to be a useful tool in the surgical treatment of spinal EDH, providing control of the adjacent levels and allowing the limitation of the extent of bony resection.

Cervical spontaneous epidural hematoma as a complication of non-Hodgkin's lymphoma

Epidural hematoma is a rare cause of spinal cord compression, which usually provokes severe neurological deficits. It is presumed to originate from venous or, more probably, arterial bleeding. Thrombocytopenia and other disorders of coagulation may precipitate the onset of epidural hematoma and facilitate the evolution of the disease. We report the case of a patient suffering from a non-Hodgkin's lymphoma with severe thrombocytopenia during a MACOP-B schedule, who presented with a spontaneous cervical epidural hematoma. We discuss the etiopathological aspects, diagnosis, and treatment of this rare cause of acute cervical spinal cord compression.

Spontaneous spinal epidural hematomas: is the role of dural arteriovenous malformations underestimated?

Two recent observations of spinal epidural hematomas (SEH) are presented: one of them was associated with iatrogenic coagulopathy, the other, apparently "spontaneous", required reoperation for early recurrence and was finally attributed to ruptured epidural arteriovenous malformation missed during the first procedure. Both patients underwent complete recovery. Although modern neuroimaging provides quick, noninvasive, and sensitive assessment of spinal epidural bleeding, we believe that preoperative spinal angiography is indicated in "spontaneous" SEH with subacute clinical course. Demonstration of underlying vascular anomaly would allow better surgical planning, complete obliteration of abnormal vessels, and prevention of recurrences. Essential epidemiological, pathogenetical, and clinical aspects of SEH are reviewed.

Solitary spinal epidural cavernous haemangioma presenting as acute epidural haematoma

This report describes a case of solitary spinal epidural cavernous haemangioma presenting as an acute epiduralhaematoma. The patient is a 50 year old diabetic female with right brachalgia and hemiparesis. Magnetic resonance imaging (MRI) demonstrated the presence of a cervical spinal epidural haematoma. The patient underwent laminectomy and total removal of the haematoma and the accompanying vascular tissue. The diagnosis of cavernous haernangioma was proven by histological examination. Because the source of bleeding in most cases of spontaneous spinal epidural haematoma is usually obscure, the authors emphasise the possibility that a small cavernous haemangioma can be one of the bleeding sources in some of these cases.

Spinal epidural hematoma. Report of a case and review of the literature

We report the case of a thoracic epidural hematoma at the T7-T9 level which occurred after placement of spinal epidural catheter for continuous anaesthesia in acute pancreatitis. The male patient felt a sudden back pain after six days of successful analgesia and became paraplegic 24 hours afterwards. An emergency laminectomy and removal of the hematoma were performed; however, the patient recovered only incompletely. We discuss the clinical signs and symptoms of spinal epidural hematoma as well as its diagnostics and therapy. The controversial views from the literature concernings its etiology are critically reviewed.

Acute spontaneous spinal epidural haematoma with temporary resolution

A case of acute spontaneous spinal epidural haematoma is presented which underwent resolution of symptoms and signs before relapsing again hours later. Cases of spontaneous remission of this condition have been reported but not subsequent relapse. Conservative management of apparently resolving cases may therefore be inappropriate.

Spontaneous spinal epidural hematoma causing paraplegia: resolution and recovery without surgical decompression

Spontaneous spinal epidural hematomas are well-recognized but rare entities. The standard treatment for these hematomas has been prompt surgical evacuation. The authors report a case of a 76-year-old man who precipitously became paraplegic secondary to a spontaneous spinal epidural hematoma and then experienced the complete resolution of his neurological deficit and the hematoma. We conclude that conservative (nonoperative) management of spontaneous spinal epidural hematomas may be appropriate in those instances in which there is early and sustained neurological recovery confirmed by radiological resolution of the lesion.

The spontaneous spinal epidural hematoma. A study of the etiology

From the literature 199 cases of spontaneous spinal epidural hematoma (SSEH) are analyzed. With these data and the vascular anatomical characteristics of the spinal epidural space, the theories on the etiology of the SSEH are discussed. There seems to be no relationship between the SSEH and arterial hypertension. The age highly affects the level-distribution of the SSEH. The authors have the opinion that the posterior internal vertebral venous plexus plays an important part in the etiology of the SSEH. In the literature the role of a vascular anomaly in the etiology of the SSEH is overestimated. The cluster-type dural artery can easily be mistaken for a vascular anomaly.

Spontaneous spinal epidural hematoma in a 7-year-old girl. Diagnostic value of magnetic resonance imaging

The authors report a 7-year-old girl who developed neck pain and stiffness over a four-day period. There was no fever, trauma, systemic illness or headache. Physical examination demonstrated subtle neurologic deficits indicative of cervical cord compression. CAT scan and subsequent Magnetic Resonance Imaging (MRI) of the cervical spine demonstrated a spinal epidural hematoma, which was evacuated surgically. Post-operative angiography failed to demonstrate a vascular abnormality. The child recovered without neurologic deficit. MRI proved to be a sensitive tool in identifying the nature and extent of this lesion, and may be considered in lieu of myelography.

Spinal epidural hematoma due to a vertebro-epidural hemangioma

We present a patient with a spinal epidural hematoma (SEH), caused by a vertebro-epidural hemangioma (VEH). A VEH has been rarely reported as a cause for a SEH and it was remarkable that the VEH was located several vertebrae above the actual hematoma. This emphasises the need for extensive spinal angiography at different levels. The VEH was treated successfully with embolization.

Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging. Case report

A traumatic epidural hematoma of the cervical spine is reported in a 13-year-old girl. The patient recovered spontaneously over several days without surgical intervention. The diagnosis was made on magnetic resonance (MR) imaging, which also demonstrated subsequent resolution of the hematoma. The etiological factors of spinal epidural hematomas are reviewed and the utility of MR imaging in differentiating other causes of acute spinal cord injury is emphasized.