Post-traumatic cervical spine epidural hematoma: Incidence and risk factors

Post-traumatic spinal hematoma in diffuse idiopathic skeletal hyperostosis (DISH)

OBJECTIVES

To determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH).

MATERIALS AND METHODS

A retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports.

RESULTS

Of 70 post-traumatic patients (54 men, median age 73, IQR 66-81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI.

CONCLUSIONS

SEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression.

CLINICAL RELEVANCE STATEMENT

Low-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation.

KEY POINTS

• Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH. • Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma. • Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.

Management of traumatic cervical epidural hematoma in patients on Xa-inhibitors: a case report and review of the literature

BACKGROUND

Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This unique case of traumatic CEH represents an even smaller subset of these cases. Management varies by symptom presentation, mechanism of injury, and other contraindications.

CASE PRESENTATION

This case presents a 32 year old African American female on an oral anticoagulant sustaining traumatic cervical hematoma after a motor vehicle collision. Patient complained of neck, abdominal, and back pain. Imaging revealed a cervical spinal hematoma at the level of C3-C6. This case discusses the management of CEH for the general population and in the setting of anticoagulation.

CONCLUSION

Management of each case of CEH must be carefully considered and tailored based on their symptom presentation and progression of disease. As the use of anticoagulation including factor Xa inhibitors becomes more prevalent, there is greater need to understand the detailed pathophysiological aspect of the injuries. Targeted reversal agents such as Prothrombin Concentrate can be used for conservative treatment. Adjunct testing such as thromboelastogram can be used to help guide management.

Traumatic cervical spine subarachnoid hemorrhage with hematoma and cord compression presenting as Brown-Séqüard syndrome: illustrative case

BACKGROUND

Spinal hematomas are a rare entity with broad etiologies, which stem from idiopathic, tumor-related, and vascular malformation etiologies. Less common causes include traumatic blunt nonpenetrating spinal hematomas with very few cases being reported. In the present manuscript presents a case report and review of the literature of a rare traumatic entity of a cervical subarachnoid hematoma in association with Brown-Séquard syndrome in a patient on anticoagulants. Searches were performed on PubMed and Embase for specific terms related.

OBSERVATIONS

A well-documented case of an 83-year-old female taking anticoagulants with traumatic cervical subarachnoid hematoma presenting as Brown-Séquard syndrome was reported. Six similar cases were identified, scrutinized, and analyzed in the literature review.

LESSONS

Traumatic blunt nonpenetrating cervical spine subarachnoid hematomas are a rare entity that can happen more specifically in anticoagulant users and in patients with arthritic changes and stenosis of the spinal canal. Rapid neurological deterioration and severe disability warrant early aggressive surgical treatment. This report has the intention to record this case in the medical literature for registry purposes.

Evolving Paralysis after Motor Vehicle Collision

Case Presentation: An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome. Discussion: Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.

Evolving Paralysis after Motor Vehicle Collision

Case Presentation

An 85-year-old male who had been prescribed prasugrel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.

Discussion

Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Percutaneous vertebroplasty in osteoporotic vertebral compression fracture with huge spinal epidural hematoma: A case report

RATIONALE

Osteoporotic vertebral compression fracture (OVCF) accompanying huge spinal epidural hematoma (SEH) is fairly rare. The aim of this report is to investigate the management strategies and treatment outcomes of OVCF accompanying SEH.

PATIENT CONCERNS

An 89-year-old female patient was admitted to hospital because of severe back pain and numbness of both lower limbs after a slight fall. The magnetic resonance imaging examination of the patient showed a fresh compression fracture at L2 accompanying a large dorsal SEH which extended from the T12 to L3 and deformed the spinal cord.

DIAGNOSIS

The patient was diagnosed with OVCF accompanying SEH.

INTERVENTIONS

Given mild neurologic deficits, the hematoma was not treated, and the patient underwent percutaneous vertebroplasty (PVP) only.

OUTCOMES

After the procedure, immediate pain relief was achieved and the numbness of both lower limbs disappeared 3 days later. Three months after the procedure, the follow-up magnetic resonance imaging revealed a complete resolution of the hematoma.

LESSONS

OVCF accompanying SEH is fairly rare, and the exact pathophysiological mechanisms are still not clear. In selected patients without or with only slight neurologic symptoms, it is reasonable to perform PVP alone in OVCF accompanying SEH. Moreover, intravertebral stability after PVP might have played a role in spontaneous resolution of SEH.

A comparative study of different stem cells transplantation for spinal cord injury: a systematic review and network meta-analysis

OBJECTIVE

This study aimed to evaluate the efficacy and safety of different stem cell types for spinal cord injury (SCI) therapy and find out the superior treatment for SCI.

METHODS

A systematic literature search was performed using PubMed, Embase, the Cochrane Library, Web of Science, VIP, CNKI, and Wan Fang from database initiation to January 30, 2021. A Bayesian network meta-analysis was performed using ADDIS software. The PROSPERO registration number was CRD42020129635.

RESULTS

Twelve studies with 642 patients were enrolled in this study. Network meta-analysis revealed that bone mesenchymal stem cells combined with rehabilitation training (BMSCs + R) were significantly more effective than rehabilitation training alone (R) in improving American Spinal Injury Association (ASIA) impairment scale (AIS)-grading improvement rate (OR=94.25, 95% CI: 6.71 to 9321.95), ASIA motor score (WMD=6.67, 95% CI: 0.83 to 12.73), ASIA Sensory Functional score (WMD=12.41, 95%CI: 3.42 to 21.72), and Barthel Index (BI) score (WMD=7.24, 95% CI: 0.21 to 14.30). However, no statistically significant differences were observed between marrow mononuclear cells combined with rehabilitation training (MNCs + R), umbilical cord-derived mesenchymal stem cells combined with rehabilitation training (UCMSCs + R), or UCMSCs alone and R on all indicators. In terms of safety, there were no serious and permanent adverse effects after transplantation of BMSCs, MNCs, or UCMSCs.

CONCLUSION

BMSCs + R may be superior to the other stem cell treatments for SCI in improving AIS grading, ASIA motor score, ASIA Sensory Functional score, and BI score. The therapeutic effects of UCMSCs and MNCs remain to be confirmed.

Single versus dual operative spine fractures in ankylosing spondylitis

OBJECTIVE

Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures.

METHODS

Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed.

RESULTS

In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4-T1, 48.6%) and thoracolumbar (T8-L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days).

CONCLUSIONS

Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.

Epidural hematoma in patients with ankylosing spondylitis requiring surgical stabilization: a single-institution retrospective review with literature analysis

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.

METHODS

Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.

RESULTS

A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.

CONCLUSIONS

AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods

Background

Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary.

Methods

A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed.

Results

Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ²=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ²=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine.

Conclusions

We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.

Spine MRI: A Review of Commonly Encountered Emergent Conditions

Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

Post-traumatic spinal hematoma in ankylosing spondylitis

PURPOSE

The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients.

METHODS

A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports.

RESULTS

Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate.

CONCLUSIONS

Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

Diagnostic Modality in Spine Disease: A Review

Spine diseases are common and exhibit several causes, including degeneration, trauma, congenital issues, and other specific factors. Most people experience a variety of symptoms of spine diseases during their lifetime that are occasionally managed with conservative or surgical treatments. Accurate diagnosis of the spine pathology is essential for the appropriate management of spine disease, and various imaging modalities can be used for the diagnosis, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and other studies such as EOS, bone scan, single photon emission CT/CT, and electrophysiologic test. Patient (or case)-specific selection of the diagnostic modality is crucial; thus, we should be aware of basic information and approaches of the diagnostic modalities. In this review, we discuss in detail, about diagnostic modalities (radiography, CT, MRI, electrophysiologic study, and others) that are widely used for spine disease.

UMR, Brinda K, Moscote-Salazar LR, Dhanireddy K. Posttraumatic Acute Spinal Epidural Hematoma of the Dorsolumbar Region

In spite of the relative common occurrence of spinal injuries, spinal epidural hematomas (SEHs) are rare lesions. Depending on the onset, site, size, and presence of neurological deficits, they can be treated conservatively or surgically. In the presented article, we report an uncommon case of posttraumatic dorsolumbar SEH and discuss the characteristic magnetic resonance imaging (MRI) imaging findings of epidural fat in the cases of traumatic spinal hematomas.

Unintentional injuries: A profile of hospitalization and risk factors for in-hospital mortality in Beijing, China

INTRODUCTION

Unintentional injuries (UIs) impose a significant burden on low- and middle-income countries (LMICs). However, available UI epidemiological data are limited for LMICs, including China. This article aimed to provide an overview of the UI hospitalization profile, identify risk factors for in-hospital mortality and provide diagnosis-specific survival risk ratios (SRRs) for reference by LMICs using hospital discharge abstract data (DAD) from Beijing, China.

PATIENTS AND METHODS

A cross-sectional study was conducted for patients sustaining UIs requiring admission. Information was retrieved from 138 hospitals in Beijing to describe the demographics, injury nature, mechanisms, severity and hospital outcomes. Multivariate logistic regression was performed to identify and evaluate risk factors for in-hospital mortality for UIs.

RESULTS

Falls (57.1%), transport accidents (19.9%) and exposure to inanimate mechanical forces (16.4%) were the leading causes of UI hospitalization. Falls and transport accidents were responsible for 94.2% of the in-hospital deaths caused by UIs. Injury mechanisms differed among sex (χ² = 5322.1, P <  0.001) and age (χ² = 24,143.3, P <  0.001) groups. Male sex (OR: 1.50, 95% confidence interval (CI): 1.23-1.79), age ≥ 85 years (OR: 16.39, 95% CI: 7.46-36.00), Barthel Index at admission ≤ 60 (OR: 25.78, 95% CI: 13.30-49.95), modified Charlson comorbidity index ≥ 6 (OR: 2.60, 95% CI: 1.91-3.55), International Classification of Diseases-based injury severity score (ICISS) < 0.85 (OR: 15.17, 95% CI: 12.57-18.30), sustaining injuries to the head/neck (OR: 23.20, 95% CI: 7.31-73.64), injuries caused by foreign body entering through natural orifice (OR: 34.00, 95%CI: 6.37-181.54) and injuries resulting from transport accidents (OR: 1.71, 95% CI: 1.41-2.07) were important risk factors for in-hospital mortality for UIs.

CONCLUSIONS

Hospital DAD are an objective and cost-effective data source that allows for a hospital-based perspective of UI epidemiology. Sex, age, functional status at admission, comorbidities, injury nature, severity and mechanism are significantly associated with the in-hospital mortality of UIs in China. This study generates a reference dataset of diagnosis-specific SRRs from a large trauma population in China, which may be more applicable in injury severity estimation using ICISS in LMICs.