Effective Steroid Treatment in Traumatic Cervical Spinal Epidural Hematoma Presenting with Delayed Tetraparesis: Two Case Reports and Literature Review

Incidence, Risk Factors, and Management of Postoperative Hematoma Following Anterior Cervical Decompression and Fusion for Degenerative Cervical Diseases

OBJECTIVE

Studies discussed few risk factors for specific patients, such as duration of disease; or surgical factors, such as duration and time of surgery; or C3 or C7 involvement, which could have led to the formation of hematomas (HTs). To investigate the incidence, risk factors especially the factors mentioned above, and management of postoperative HTs following anterior cervical decompression and fusion (ACF) for degenerative cervical diseases.

METHODS

Medical records of 1,150 patients who underwent ACF for degenerative cervical diseases at our hospital between 2013 and 2019 were identified and reviewed. Patients were categorized into the HT group (HT group) or normal group (no-HT group). Demographic, surgical and radiographic data were recorded prospectively to identify risk factors for HT.

RESULTS

Postoperative HT was identified in 11 patients, with an incidence rate of 1.0% (11 of 1,150). HT occurred within 24 hours postoperatively in 5 patients (45.5%), while it occurred at an average of 4 days postoperatively in 6 patients (54.5%). Eight patients (72.7%) underwent HT evacuation; all patients were successfully treated and discharged. Smoking history (odds ratio [OR], 5.193; 95% confidence interval [CI], 1.058-25.493; p = 0.042), preoperative thrombin time (TT) value (OR, 1.643; 95% CI, 1.104-2.446; p = 0.014) and antiplatelet therapy (OR, 15.070; 95% CI, 2.663-85.274; p = 0.002) were independent risk factors for HT. Patients with postoperative HT had longer days of first-degree/intensive nursing (p < 0.001) and greater hospitalization costs (p = 0.038).

CONCLUSION

Smoking history, preoperative TT value and antiplatelet therapy were independent risk factors for postoperative HT following ACF. High-risk patients should be closely monitored through the perioperative period. Postoperative HT in ACF was associated with longer days of first-degree/intensive nursing and more hospitalization costs.

Spontaneous Cervical Epidural Hematoma Following COVID-19 Illness Presenting to a Chiropractor: A Case Report

Cervical epidural hematoma (CEH) is a rare and potentially fatal condition in which blood accumulates in the epidural space of the cervical spine. A 64-year-old man presented to a chiropractor with a two-week history of sudden-onset neck pain, shoulder pain, occipital headache, and numbness in the shoulders and upper extremities. He had recovered from a mild course of coronavirus disease 2019 (COVID-19) illness one month prior. The patient's primary care provider had previously prescribed a nonsteroidal anti-inflammatory drug for his neck pain. However, his symptoms worsened, and he visited the emergency department where he had unremarkable cervical spine radiographs and was discharged with a diagnosis of neck strain. The chiropractor ordered cervical spine magnetic resonance imaging (MRI), revealing a ventral CEH extending from C2 to C5. The chiropractor referred the patient to a nearby hospital for urgent management. The patient was admitted and observed, progressively improved, and did not require surgery. After 10 weeks in the hospital the patient was asymptomatic, a follow-up MRI revealed resolution of the CEH, and the patient was discharged. While the current case highlights a temporal relationship between COVID-19 and CEH, further research is needed to determine if COVID-19 is a risk factor for this condition. Clinicians who encounter patients with spinal disorders must be able to recognize the clinical features of CEH and refer these patients for emergency care and/or neurosurgical evaluation.

Delayed postoperative spinal epidural hematoma after anterior cervical discectomy and fusion: A case report

Background

Postoperative spinal epidural hematoma (POSEH) causes rapid neurological deficits within 24 h following the operation and can be fatal. However, some POSEH symptoms manifest three days after the operation, also known as delayed POSEH (DPOSEH). Little attention has been provided upon DPOSEH owing to its rare incidence, resulting in serious consequences upon occurrence. To date, no cases of delayed POSEH after anterior cervical surgery have been reported.

Case presentation

We describe a case of DPOSEH that presented with delayed neurological deficits on the fifth day after anterior cervical discectomy and fusion (ACDF) surgery. Methylprednisolone was administered but showed no efficacy. MR revealed low T1 and strip long T2 signals located behind discs. After emergency surgical decompression, the patient's muscle strength returned to the preoperative state. However, his muscle strength decreased again on the seventh postoperative day, and the patient's family refused further surgery. Nine months after ACDF, the patient died of septic shock and respiratory failure.

Conclusions

DPOSEH can occur after three days or more following anterior cervical surgery; hence, monitoring of neurological function is suggested to be extended. Complete evaluation of risk factors, timely recognition, and differentiation of neurological symptoms are required for spine surgery. In the case of DPOSEH, methylprednisolone can be administered reasonably during the transition period. However, if there is no resolution of symptoms, emergency surgery should be performed as soon as possible.

A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke

BACKGROUND

Spinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately.

CASE REPORT

We describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.

Treatment of hematomas after anterior cervical spine surgery: A retrospective study of 15 cases

OBJECTIVE

Postoperative hematoma is a rare and dangerous complication of cervical spine surgery. The aim of this study was to investigate the incidence and related factors of postoperative hematoma, and to report on 15 cases at our institution over a 6-year period.

METHODS

Fifteen cases of postoperative hematoma were retrospectively identified. We investigated their neurological outcomes, characteristics, and surgical data, and identified risk factors associated with postoperative (PO) hematoma. Patients with hematoma were compared to those with no hematoma, in order to identify risk factors.

RESULTS

Retropharyngeal hematomas developed in seven cases and epidural hematomas in eight. The total incidence of postoperative hematoma was 1.2%: 0.5% retropharyngeal hematomas and 0.6% spinal epidural hematomas. At time of onset, the severity of paralysis was assessed as grade B in one case, grade C in six cases, and grade D in eight cases. Risk factors for PO hematoma were: (1) presence of ossification of the posterior longitudinal ligament (OPLL) (P<0.001); (2) longer operative duration (P=0.048); (3) greater number of surgical levels (P=0.02); and (4) higher body mass index (BMI; P=0.035). There was no significant difference in modified Japan Orthopedic Association scores between the hematoma group and non-hematoma group (P>0.05).

CONCLUSION

Precise preoperative preparation and systematic evaluation are central to successful management of PO hematoma after anterior cervical surgery. Risk factors for PO hematoma include multilevel decompression, OPLL, higher BMI, and longer operation time.