A patient with delayed traumatic cervical spinal epidural haematoma presenting with hemiparesis

Delayed spinal epidural hematoma following T1 chance fracture: An illustrative case and review of the literature

Background

A Chance fracture is a traumatic fracture of the thoracic or lumbar spine that occurs secondary to a flexion-distraction injury. Although patients with chance fractures rarely present with neurologic deficits, a subset may become symptomatic from spinal epidural hematomas (SEH) warranting emergent decompressive surgery.

Case Description

An 87-year-old female on anticoagulation presented with a T1 Chance fracture after a fall. She was originally neurologically intact, but became paraplegic over the next 10 h. When the cervical/thoracic magnetic resonance revealed a SEH markedly compressing the cord between the C7-T1 levels, she underwent an emergent decompression; she also had a C5-T4 instrumented fusion. Postoperatively, she regained lower limb function, but expired on postoperative day 5 due to respiratory complications likely attributed to the prolonged surgery for the spinal instrumentation.

Conclusion

Delayed SEH rarely occur following spinal Chance fractures. Here, an 87-year-old female on anticoagulation developed the 10-h delayed onset of a SEH with paraplegia attributed to a T1 Chance fracture at the C7-T1 level. Although she regained neurological function following the emergent decompression, she expired 5 days later likely due to the extended operative time/blood loss from the C5-T4 fusion that could have been avoided.

Incidence and Clinical Features of Postoperative Symptomatic Hematoma after Spine Surgery: A Multicenter Study of 45 Patients

Introduction

Symptomatic postoperative hematoma after spine surgery is a rare but serious complication. The objective of this study was to investigate the incidence and clinical features of symptomatic postoperative hematoma after spine surgery.

Methods

We retrospectively identified 10,680 patients who underwent spine surgery between 2002 and 2012 in nine hospitals. We reviewed the incidence of postoperative hematoma and its clinical features, including time before onset, main symptoms, and neurological outcomes.

Results

The overall incidence of symptomatic postoperative hematoma after spine surgery was 0.4% (45/10,680). Postoperative hematoma was more frequent after thoracic spine surgery than after cervical or lumbar surgery. The onset of postoperative hematoma occurred at an average of 2.6 days (range 0-14 days) postoperatively. The chief symptoms caused by postoperative hematoma after spine surgery were tetra/paraplegia in 30 patients, hemiplegia in eight patients, intractable pain in five patients, and airway dysfunction in two patients. Surgical evacuation of the spinal epidural hematoma resulted in improvement of at least one grade in 35 patients, while four patients had complete motor paralysis even after evacuation surgery.

Conclusions

We report the clinical details of 45 patients with postoperative hematoma after spine surgery. This information could assist surgeons to make a prompt diagnosis and perform early evacuation surgery for postoperative hematoma following spine surgery.

Massage-induced spinal epidural hematoma presenting with delayed paraplegia

BACKGROUND

Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury.

OBJECTIVE

We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia.

CASE REPORT

A 20-year-old man presented with bilateral lower extremity weakness and numbness 3 h prior to presentation. 3 days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flow or AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma.

CONCLUSION

Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome.

Improper Use of Thrombolytic Agents in Acute Hemiparesis Following Misdiagnosis of Acute Ischemic Stroke

Objective

Acute hemiparesis is often an early presentation of acute ischemic stroke, though it can occur in various disorders. This study aimed to investigate the improper use of thrombolytic agents for patients with acute hemiparesis, following the misdiagnosis of acute ischemic stroke.

Methods

We analyzed the clinical and radiological data of nine patients initially misdiagnosed with cerebral stroke in the emergency room from May 2013 to January 2017. All the patients were treated with tissue plasminogen activator (TPA) owing to the presence of acute hemiparesis. Subsequently, emergent computed tomography scan showed no intracranial hemorrhage. Clinical findings including neurological deficits, clinical course, and related complications were detected and analyzed.

Results

Acute hemiparesis was observed in the following conditions: spontaneous spinal epidural hematoma, Brown-Séquard syndrome caused by cervical disc herniation, cervical epidural abscess, hypoglycemia in the presence of an old stroke, and seizure or convulsion disorder. Although acute hemiparesis was regarded as a contraindication, inappropriate TPA administration did not aggravate the neurological condition in any of the patients who required surgery.

Conclusion

Upon presentation of acute hemiparesis, various conditions mimicking cerebral stroke should be considered to avoid misdiagnosis. We suggest that physicians should exercise caution when prescribing thrombolytic agents.

Spinal Epidural Hematoma Due To Tyre-Blast Injury: A Case Report

STUDY DESIGN

A retrospective case report.

OBJECTIVE

The objective of this article is to report a spinal epidural hematoma (SEH) due to shock wave.

SUMMARY OF BACKGROUND DATA

SEH is an infrequent condition. Most of SEH's are spontaneous. We have reported an SEH traumatic case without bone lesions due to exploding truck tire. A different category of blast injuries is the one related with exploding tyres. Shock waves are the main mechanism that is responsible for blast injuries. We are presenting the first report of acute SEH due to shock wave.

METHODS

A 33-year-old man was brought to the emergency department with complaints of weakness and numbness of the upper extremities. There was an epidural high-signal density without osseous lesion in computerized tomography from the level of C2 to C5, and there was a T2-weighted hyperintense lesion in magnetic resonance imaging from the level of C2 to C5 with compression of the spinal cord the anterior and posterior which proved to be an SEH.

RESULTS

The patient was discharged from the hospital with complete neurologic recovery.

CONCLUSION

SEH should be considered possible in the blast injury. SEH condition carries a significant risk of morbidity and mortality without early recognition and rapid management.

LEVEL OF EVIDENCE

5.

Imaging characteristics of cervical spine extra-arachnoid fluid collections managed conservatively

OBJECTIVE

Determine the MRI characteristics of large post-traumatic cervical spine extra-arachnoid collections managed conservatively in clinically stable patients and whether evidence of clinical or imaging deterioration materialized.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective search for all patients (>16 years old) over a 17-months period who had an extra-arachnoid fluid collection reported on a post-traumatic cervical spine MRI. Patients were excluded if they had surgery for an unstable fracture (n = 21), emergent decompression (n = 1) or lacked a follow-up MRI within 15 days (n = 1). Two MSK radiologists recorded the size, morphology and MRI signal characteristics of the collections.

RESULTS

Eight patients (5 male, 3 female) met the inclusion criteria (mean age 40 years; range 19-78 years). Seven of the eight patients had fluid collections that demonstrated thin, tapered margins, extended >7 vertebral bodies and involved >180 degrees of the spinal canal. The signal characteristics of these collections varied: hyper-T1/iso-T2 (n = 1), iso-T1/T2 (n = 3), hyper-T1/hypo-T2 (n = 3) and mixed-T1/T2 (n = 1). Six of seven collections were ventral. Follow-up MRI demonstrated resolution/significant decrease in size (n = 4 between 1 and 12 days) or no change/slight decrease in size (n = 3; between 2 and 11 days). None of the seven fluid collections enlarged, no patient had abnormal cord signal, and no patient's neurologic symptoms worsened. One of eight patients had a dorsal "mass-like" collection that was slightly smaller 9 days later.

CONCLUSION

In stable patients with large, tapered post-traumatic cervical spine extra-arachnoid collections managed non-surgically, none developed (1) clinical worsening, (2) abnormal cord signal or (3) collection enlargement, regardless of the collection's signal characteristics.

Delayed Presentation of a Cervical Spinal Epidural Abscess of Dental Origin after a Fall in an Elderly Patient

Spinal epidural abscesses are an uncommon cause of spinal cord injury but, depending on the size and presence of neurological deficits, urgent neurosurgical intervention may be required. We present a unique case of a patient presenting with a spinal epidural collection several days after a fall. While a spinal epidural hematoma was suspected based on the patient’s history and MRI findings, a spinal epidural abscess was found during surgery. The patient underwent laminectomy and instrumented fusion with successful treatment of her infection.