Spontaneous cervical epidural haematoma during pregnancy

Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review

BACKGROUND

Spontaneous spinal epidural hematomas (SSEH) are rare yet severe conditions. In pregnancy, this condition is challenging to diagnose and treat because of the risks to the mother and fetus. This study reviews the literature on SSEHs in pregnancy.

METHODS

We performed a systematic review of the English literature on SSEHs from 1990 until 2018. Outcome measures were mode of presentation, risk factors, initial neurologic findings, diagnostic investigations, site and size of the SSEH, treatment, neurologic recovery, and survival.

RESULTS

Fourteen publications (16 patients) were included. Two patients presented in the second trimester, with the remainder in the third trimester. All patients presented with back pain, and 15 subsequently developed spinal cord dysfunction. Magnetic resonance imaging (MRI) was performed in all cases. The cervicothoracic region was the most commonly affected, and the average hematoma size extended across 3.9 vertebral levels. All patients with neurologic dysfunction underwent surgical decompression. In women under 32 weeks' gestation, caesarean section was not routinely performed. In contrast, women of gestational age of 32 weeks or more underwent a caesarean section prior to spinal decompression. Women without neurologic dysfunction underwent a caesarean section and neurologic monitoring without decompression. All patients with abnormal neurology improved after surgery, except 1 patient. No patients died.

CONCLUSIONS

In pregnancy, SSEHs typically present in the second or third trimesters with back pain, predominantly in the cervicothoracic region, followed by progressive neurologic dysfunction. MRI is diagnostic, and the treatment depends on the patient's neurologic dysfunction and gestational age.

Nonsurgical Intervention in a Preeclamptic Patient with Spontaneous Spinal Epidural Hematoma

Background

Spontaneous epidural hematoma (SEH) is a rare finding in pregnancy, especially since most pregnant women do not have risk factors for developing SEH. The presence of epidural anesthesia can delay the diagnosis of SEH in pregnant patients. Immediate surgical decompression is the current standard of care for treating SEH.

Case Presentation

We present the case of a 37-year-old pregnant woman with preeclampsia with severe features who developed neurological deficits that were initially attributed to her epidural anesthesia. She was eventually found to have SEH with spinal stenosis at T5-T6 on MRI. Oral antihypertensives were used to keep the patient's blood pressures within normal limits, and she subsequently had complete resolution of her neurological symptoms and her SEH on imaging.

Conclusion

Preeclampsia may contribute to the development of SEH in pregnancy, and strict blood pressure control may potentially provide a safe and effective alternative to neurosurgery for these patients.

Spontaneous Spinal Epidural Haematoma in a 34-week Pregnant Woman: A Case Report and Literature Review

Acute spontaneous spinal epidural haematoma is uncommon; however, it can result in permanent neurological damage if not promptly treated. It occurs very rarely during pregnancy. We report a case of acute spontaneous spinal epidural hematoma in a 34-year-old primigravida woman at 34 weeks’ gestation who presented with sudden back pain and paraplegia. Emergency spinal decompression surgery was done with the continuation of pregnancy. We discuss the presentation and management of the rare condition with a review of the literature.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report

Background

Spontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period.

Case presentation

We present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach.

Conclusions

The case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.

Spontaneously Resolved Recurrent Cervical Epidural Hematoma in a 37-Week Primigravida

Study Design Case report. Objective To describe a patient with a recurrent spontaneous spinal epidural hematoma (SSEH) during pregnancy that had spontaneous remission. Methods A 27-year-old primigravida at 37 weeks' gestation suddenly felt a strong left shoulder pain without any trauma. She had a history of fenestration for a spontaneous cervical hematoma when she was 18 years old. An emergency magnetic resonance imaging revealed a recurrence of the cervical epidural hematoma at the C4-T1 level, but she had no paralysis. Results The patient subsequently underwent a cesarean section and delivered a healthy male infant. Her spinal epidural hematoma disappeared. Multislice computed tomography showed no evidence for a vascular malformation or tumor. Three years after the initial cesarean section, she underwent a second one and delivered another male infant. Conclusions We report on a rare case of recurrent SSEH during pregnancy with no neurologic deficits that was treated nonoperatively with close observation and resulted in spontaneous resolution. In such patients with no neurologic deficits, nonoperative management with close observation may be a reasonable alternative.

Remote spinal epidural haematoma after spinal anaesthesia presenting with a 'spinal lucid interval'

An obstetric patient who had no significant risk factors developed a spinal epidural haematoma remote from the site of needle puncture (for administration of spinal anaesthesia). The clinical deficits were manifest after recovery from the motor blockade had started a phenomenon that we have termed as a 'spinal lucid interval'. The patient developed flaccid paraplegia with a sharp sensory level and urinary retention. The patient underwent emergency laminectomy and evacuation of the haematoma. She gradually recovered near normal power and was ambulant independently and had normal sphincter function at follow-up.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns

OBJECTIVE

Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines.

METHODS

Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors.

RESULTS

In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks.

CONCLUSION

This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Spontaneous cervical spinal epidural hematoma in the postpartum period

STUDY DESIGN

We present the case study of a 31-year-old lady who had a spontaneous cervical spinal epidural hematoma in the postpartum period and who presented with sudden onset of neck pain and lower limb weakness for which an emergency decompressive laminectomy was performed with neurological recovery.

OBJECTIVE

To report on the spontaneous spinal epidural hematoma in the postpartum period, which is a rare complication during pregnancy and requires early recognition and expedient intervention to prevent permanent neurological sequelae.

SUMMARY OF BACKGROUND DATA

This complication has been described only once previously in the postpartum period. The recovery of the patient described here highlights the importance of early recognition and surgical intervention.

METHODS

A case report of a spontaneous cervical spinal epidural haematoma in the postpartum period is presented and the pertinent literature is then reviewed.

RESULTS

The patient had neurological recovery at 1-year follow-up, although she required clean intermittent self-catheterization once daily for bladder dysfunction.

CONCLUSION

Early recognition and intervention for our patient allowed for neurological recovery with a spontaneous cervical spinal epidural hematoma in the postpartum period.

Epidural haematoma: Rare complication after spinal while intending epidural anaesthesia with long-term follow-up after conservative treatment

Epidural anaesthesia (EA) is an extensively used procedure for many surgeries. Increase incidence of bleeding in the epidural space [epidural haematoma (EH)] is reportedly more common in patients with altered coagulation and patients on anticoagulation treatment. EH secondary to spinal while intending EA for caesarean section (C-section) in a healthy individual leading to transient or persistent neurological problems is very rare. We report a case of EH after spinal while intending EA for C-section in a healthy young female along with 5-yrs follow-up after conservative treatment.

Spontaneous cervical epidural hematoma during pregnancy: case report and literature review

Spontaneous spinal epidural hematoma (SSEH) during pregnancy is rare and may result in permanent damage if not promptly treated. There were few studies discussing the etiology, presentation and treatment of SSEH during pregnancy. The authors describe a case of spontaneous cervical epidural hematoma during pregnancy, which was diagnosed by magnetic resonance imaging (MRI) and managed with surgical evacuation. A retrospective review of a case of spontaneous epidural hematoma of spine during pregnancy was performed. The clinical features, diagnoses, treatments and outcomes of all cases were analyzed. Precise diagnosis without delay and rapid surgical treatment are essential for the management of SSEH during pregnancy.

[Spontaneous spinal epidural haematoma during pregnancy]

Spontaneous spinal epidural haematomas are quite rare. We report here the case of a 27-year-old woman, without previous history of relevant medical disorder, who presented with acute paraplegia at 36 weeks of gestation. MRI performed in emergency revealed a T8 epidural haematoma. The management consisted in an emergency Caesarean section under general anaesthesia, followed immediately by a T8 laminectomy allowing the spinal cord decompression 14 hours after the first symptoms. Neurologic recovery was rapid and complete, except for bladder dysfunction persisting one month later. Spontaneous spinal epidural haematomas require a prompt diagnosis because neurologic prognosis essentially depends on the interval of time between onset of symptoms and surgical decompression. Obstetrical management especially depends on the term of pregnancy. For the anaesthesiologist, the difficulty is the management of both pregnant condition (full stomach general anaesthesia) and spinal cord compression (maintenance of spinal cord perfusion pression and limitation of ischaemia and oedema).

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.