Spontaneous spinal epidural hematoma presenting with quadriplegia after sit-ups exercise

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.

Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome

Background:

Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively.

Case Description:

A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit.

Conclusions:

Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.

Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compression is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With spinal cord compression, there is an indication for urgent surgical decompression. Here, we present a 64-year-old woman who developed sudden thoracic and lower back pain accompanied by severe paraparesis and urinary retention after sneezing abruptly. An MRI revealed a posterior thoracic epidural hematoma extending from the T6 to T11 vertebral level with spinal cord compression. Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.

Spontaneous spinal epidural hemorrhage from intense piano playing

Spontaneous spinal epidural hematoma (SSEH) is a rare but real neurosurgical emergency. It is caused by atraumatic rupture of the vertebral epidural vein that results in nerve root or spinal cord compression. Most cases of SSEH have a multifactorial etiology, including congenital and acquired coagulopathies; platelet dysfunction; vascular malformation; tumors; uncontrolled hypertension; pregnancy; and, very rarely, activities requiring Valsalva. Herein we reported the case of a young pianist who was attacked by SSEH during piano practice. Playing the piano is a joyful, relaxing entertainment; however, this musical activity can be a highly demanding physical and mental exercise for pianists. Emotional and expressive performance, especially in professional performing, has been reported to result in significant increase of sympathetic and decrease of parasympathetic activities and thus influence the cardiorespiratory variables. The increased biomechanical stress from fluctuating hemodynamics was thought to trigger the rupture of her spinal arteriovenous malformation.

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 Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature

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.