Spontaneous Spinal Epidural Hematoma: A Study of 55 Cases Focused on the Etiology and Treatment Strategy

Spontaneous spinal hematomas: A case series

PURPOSE

Spontaneous spinal hematoma (SSH), a rare neurological disorder, demands immediate diagnostic evaluation and intervention to prevent lasting deficits. This case series analyzes instances, particularly highlighting cases where vascular causes were identified despite inconclusive initial imaging.

METHODS

In a retrospective study of 20 patients treated for SSH at a Level I spine center from 01/01/2017 to 11/15/2023, we examined demographics, clinical presentation, imaging, and treatment details. Excluding traumatic cases, we present 4 instances of SSH associated with diverse vascular pathologies.

RESULTS

Patient ages ranged from 39 to 85 years, with a median age of 66 years. 45% were male, and 55% were female. Among 20 cases, 14 were epidural hematomas, 4 subdural, 1 combined epidural and subdural, and 1 subarachnoid hemorrhage. 85% presented with neurological deficits, while 3 solely had pain-related symptoms. 55% were under anticoagulant medication, and vascular anomalies were found in 25% of cases. The cause of SSH remained unclear in 20% of cases. MRI was performed for all patients, and DSA was conducted in 25% of cases. The 4 highlighted cases involved individuals with distinct vascular pathologies managed surgically.

CONCLUSION

Urgent attention is crucial for SSH due to possible lasting neurological consequences. The study emphasizes comprehensive diagnostics and surgical exploration, especially in cases with unclear etiology, to identify and address vascular causes, preventing hematoma progression or recurrence. Despite their rarity, vascular malformations contributing to spinal hematomas warrant particular attention.

Delayed postoperative spontaneous spinal epidural hematoma: Case based review

INTRODUCTION AND IMPORTANCE

Postoperative spontaneous spinal epidural hematoma (SSEDH) is a rare complication in clinical practice. Despite its rarity, SSEDH is a critical emergency situation associated with neurological deficits, and improper or delayed management may lead to severe consequences. Therefore, surgical operators should familiarize themselves with SSEDH and give it more attention.

CASE PRESENTATION

This study describes the case of an elderly woman diagnosed with a left unilateral femoral neck fracture, severe osteoporosis, and multi-segmental vertebral compression fracture. Following artificial femoral head replacement surgery, the patient developed postoperative SSEDH. Subsequently, the patient underwent surgical removal of the posterior epidural hematoma and spinal cord decompression. The postoperative recovery was favorable, with normal muscle strength and tension in both lower limbs. A 4-year follow-up showed no complications.

CLINICAL DISCUSSION

The occurrence of SSEDH during the perioperative period of non-spinal surgeries is relatively uncommon. However, SSEDH is a neurosurgical emergency associated with neurological deficits, and prompt surgical intervention is crucial for successful treatment.

CONCLUSION

Clinicians should enhance their knowledge of SSEDH and remain vigilant towards this condition. Literature review highlights the significance of factors such as aging in the development of SSEDH following non-spinal surgeries in the perioperative period.

Clinical outcome after surgical management of spontaneous spinal epidural hematoma

PURPOSE

Spontaneous spinal epidural hematoma (SSEH) is a rare pathology characterized by a hemorrhage in the spinal epidural space without prior surgical or interventional procedure. Recent literature reported contradictory findings regarding the clinical, radiological and surgical factors determining the outcome, hence the objective of this retrospective analysis was to re-assess these outcome-determining factors.

METHODS

Patients surgically treated for SSEH at our institution from 2010 - 2022 were screened and retrospectively assessed regarding management including the time-to-treatment, the pre-and post-treatment clinical status, the radiological findings as well as other patient-specific parameters. The outcome was assessed using the modified McCormick Scale. Statistical analyses included binary logistic regression and Fisher's exact test.

RESULTS

In total, 26 patients (17 men [65%], 9 women [35%], median age 70 years [interquartile range 26.5]) were included for analysis. The SSEHs were located cervically in 31%, cervicothoracically in 42% and thoracically in 27%. Twenty-four patients (92%) improved after surgery. Fifteen patients (58%) had a postoperative modified McCormick Scale grade of I (no residual symptoms) and 8 patients (31%) had a grade of II (mild symptoms). Only 3 (12%) patients remained with a modified McCormick Scale grade of IV or V (severe motor deficits / paraplegic). Neither time-to-treatment, craniocaudal hematoma expansion, axial hematoma occupation of the spinal canal, anticoagulation or antiplatelet drugs, nor the preoperative clinical status were significantly associated with the patients' outcomes.

CONCLUSION

Early surgical evacuation of SSEH generally leads to favorable clinical outcomes. Surgical hematoma evacuation should be indicated in all patients with symptomatic SSEH.

Ultraearly Hematoma Evacuation (<12 Hours) Associated with Better Functional Outcome in Patients with Symptomatic Spontaneous Spinal Epidural Hematoma

BACKGROUND

Early decompressive surgery within 24 hours improves the functional outcome of patients with traumatic spinal cord injury; however, little is known about the effect of early surgery for spontaneous spinal epidural hematoma (SSEH). In this study, we aimed to investigate the effectiveness of ultraearly hematoma evacuation (<12 hours) for SSEH.

METHODS

Patients with SSEH treated with surgical hematoma evacuation at our institution between January 2000 and July 2021 were retrospectively analyzed. Neurologic function was evaluated using the American Spinal Injury Association Impairment Scale (AIS). AIS grades A-C were defined as severe, and grades D and E as mild. AIS grades D and E at the final follow-up were considered favorable outcomes. Preoperative status and postoperative treatment results were compared between patients who had hematoma evacuation within 12 hours of onset and those who underwent surgery after 12 hours.

RESULTS

Twenty-five consecutive patients were included in the analysis. Preoperatively, 23 patients (92.0%) had severe AIS. Fourteen (56.0%) patients underwent early surgery. At the final follow-up, 21 patients (84.0%) achieved favorable outcomes. Patients treated with ultraearly surgery had significantly better outcomes (100% vs. 63.6%, P = 0.03). Additionally, the time from onset to surgery was significantly shorter in patients with AIS improvement by 2 or more grades than that in patients with AIS improvement of 1 or less (median 8 hours vs. 14 hours, P = 0.0001).

CONCLUSIONS

Ultraearly surgery within 12 hours for SSEH was associated with better functional outcomes.

Spinal Epidural Hematoma Due to Venous Congestion Caused by Nutcracker Syndrome

The causes of spinal epidural hematoma (SEH) have been attributed to coagulopathy, trauma, vascular anomalies, and so forth. The incidence of vascular anomalies shown by digital subtraction angiography has been reported to be 15%, and most cases have been reported to be spinal epidural arteriovenous fistulae. SEH has rarely been caused by venous congestion. We report a case of SEH in a 78-year-old male who presented to our emergency department with sudden-onset back pain, followed by complete paraplegia with bladder and rectal disturbance. Magnetic resonance imaging revealed a dorsally placed extradural hematoma extending from T10 to L1. An urgent laminectomy from T11 to L2 was performed. Computed tomography angiography (CTA) performed 1 week after the operation showed compression of the left renal vein between the aorta and superior mesenteric artery with dilation of the surrounding veins, including the spinal epidural venous plexus, at the same level as the hematoma. This was diagnosed as Nutcracker syndrome (NCS), which was consistent as a cause of SEH. The patient's symptoms gradually improved, and after 6 months, he regained normal strength in his lower extremities, but bladder and rectal disturbance remained and required intermittent self-catheterization. We chose conservative treatment for NCS, and SEH did not recur until the patient died of a cause unrelated to SEH or NCS. SEH could occur secondary to venous congestion including NCS. We emphasize the importance of investigating venous return to evaluate the etiology of SEH, which can be clearly visualized using CTA.

Treatment of spontaneous spinal epidural hematoma in children: analysis of 25 cases

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency, presenting as sudden onset of back pain and weakness of lower extremities. Many patients have no definite cause. Some cases of SSEH caused by vascular malformation have been reported. The treatment strategy remains controversial. This study aimed to analyze the causes of SSEH and proposed a treatment strategy according to clinical outcomes of patients at a single institution.

METHODS

A total of 25 cases of SSEH under 18 years of age treated between March 2004 and July 2021 were retrospectively analyzed.

RESULTS

The mean age of the first SSEH onset was 7.1 years. The most common location was cervicothorax. Nine patients suffered from multiple episodes. Twenty-three patients underwent spinal digital subtraction angiography (DSA), of which seven (30.4%) patients had positive findings: three cases had epidural artery venous fistula (AVF), two cases had epidural artery venous malformation (AVM), and two cases had abnormal concentration of contrast agent. Seventeen patients received surgery. Eleven patients (44%) were diagnosed as vascular malformation by either DSA or pathology. The follow-up rate was 80%, with 20 patients (80%) achieving satisfactory clinical outcome. Risk factors for poor clinical outcome included multiple episodes (p = 0.028) and higher Aminoff-Logue score (p = 0.005).

CONCLUSION

Spinal epidural vascular malformation is a significant cause of SSEH. Spinal DSA is necessary. Surgery should be recommended for patients with multiple episodes, positive findings on DSA, or severe neurological deficits. Conservation therapy can be considered for other patients, but long-time follow-up is necessary.

Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma: A Multicenter Retrospective Study

Background and Objectives

Spontaneous spinal epidural hematoma (SSEH) is an uncommon but serious condition with a high morbidity rate. Although SSEH is related to numerous risk factors, its etiology remains unclear. There is a paucity of data on its prognostic factors. We aim to evaluate prognostic factors for SSEH in this study.

Method

A retrospective study was performed on patients who were admitted for SSEH in 3 academic neurosurgical centers from January 2010 to June 2021. Clinical parameters, including clinical condition on admission, anticoagulants use, imaging modality, the timing and type of surgery performed, and outcomes, were collected. Prognostic factors were analyzed. The Frankel scale was used to assess the clinical condition.

Results

A total of 105 patients with SSEH were retrieved from medical records, with a mean age of 51.3 years. Eighty-three patients (79%) complained of acute onset of severe neck or back pain. Eighty-two patients (78%) suffered from moderate to severe neurologic deficits (Frankel scale A–C). Anticoagulation usage was found in 20% of cases. Lower thoracic spine (p = 0.046), use of anticoagulants (p = 0.019), sphincter function disfunction (p = 0.008), severe neurologic deficits at admission (p < 0.001), and rapid deterioration (<1 hour, p = 0.004) were found to be associated with poor outcomes. Surgical decompression was performed in 74 (70%) cases. The univariate and multivariate analysis revealed that preoperative severe neurologic deficits (p = 0.005) and extended paraplegia time (>12 hours, p = 0.004) were independent adverse prognostic factors. The univariate analysis revealed that lower thoracic spine location (p = 0.08) and rapid progression (<6 hours, p = 0.005) were correlated with poor prognosis, but the multivariate analysis failed to identify them as independent prognostic factors.

Discussion

Adverse prognostic factors for SSEH might include thoracic segment location, use of anticoagulation, severe neurologic deficits on admission, sphincter dysfunction, and rapid progression. Preoperative neurologic deficit and extended paraplegia time were strongly correlated with the prognosis in the subset of patients who underwent surgical decompression. Timely surgical decompression is recommended for patients with moderate/severe neurologic deficits or progressive neurologic deterioration.

Prognostic factors for spontaneous spinal epidural hematoma: a multicenter case-control study

BACKGROUND

To determine the optimal treatment for spontaneous spinal epidural hematoma (SSEH). The aim of this study was to identify factors associated with SSEH.

METHODS

In 62 patients with SSEH, several patient-related parameters were analyzed as candidate factors associated with Frankel grade before treatment or at the last follow-up. These parameters were compared between patients with and without surgery. In addition, multivariate ordinal logistic regression analysis was used to identify factors significantly associated with Frankel's grade before treatment or at the last follow-up.

RESULTS

There were significant differences in age, location of the hematoma, and Frankel grade before treatment and at the last follow-up between surgical and nonsurgical cases in all patients, but there were no significant differences in any of these parameters when comparing patients with pre-treatment Frankel grade C. The location of the hematoma was significantly associated with the severity of paralysis before treatment. In surgical cases, the time from onset to surgery and the location of the hematoma was significantly associated with the prognosis. When the time from onset to surgery was evaluated using the criteria of 12, 24, and 48 h, 24 and 48 h had a significant impact on the prognosis. In the analysis of nonsurgical cases, only the vertical size of the hematoma was significantly associated with prognosis.

CONCLUSION

The time from onset to surgery and the location of the hematoma were prognostic factors in surgical cases, while the vertical size of the hematoma was a prognostic factor in nonsurgical cases.

Onyx embolization of a spinal epidural hemorrhage caused by thoracic spinal epidural arteriovenous fistula: A case report and literature review

Spinal epidural hemorrhages (SEDH) caused by spinal epidural arteriovenous fistulas (SEAVFs) are rare; thus, their specific pathogenesis has not been explained. Furthermore, the standard treatment for SEAVFs has not yet been defined. Here we report the case of a 36-year-old Chinese man who experienced acute onset chest pain and tightness. His symptoms rapidly aggravated until the lower limbs were unable to support him. Spinal magnetic resonance angiography (MRA) revealed a localized SEAVF and a secondary spinal cord lesion at the T4 level. Digital subtraction angiography (DSA) confirmed the presence of the SEDH/SEAVF at the T3-4 level with the left radicular artery feeding the fistula. Based on DSA and MRA findings, SEDH, local spinal cord infarction, and spinal venous reflux disorder were conditionally diagnosed. Using the arterial route, Onyx-34 was injected into the fistula to embolize the feeding arteries and the venous system. Angiography was performed after the microcatheter was withdrawn, and no residual fistula or anterior spinal artery was observed. The six-week follow-up MRI showed acceptable healing of the SEAVF, and the patient improved neurologically. This case suggests that endovascular treatment with Onyx-34 embolization should be considered a promising treatment strategy for this type of complicated SEAVF.

Extent of spinal canal obliteration as prognostic factor for functional outcome in patients with spontaneous spinal epidural hematoma: a retrospective study

BACKGROUND

Spontaneous spinal epidural hematoma (SSEDH) is a rare condition with potentially devastating consequences. Known prognostic factors are short time to surgery, preoperative neurologic condition, and age. The aim of this study was to investigate the impact of the transversal hematoma extent with its subsequent spinal canal obliteration on outcome in patients with SSEDH.

METHODS

A retrospective study including all patients that underwent surgery due to SSEDH at the University Hospital of St. Poelten between 1/7/2005 and 30/6/2020 was conducted. The percentage of spinal canal obliteration at the level where the hematoma was most prominent was calculated and correlated to functional outcome.

RESULTS

A total of 17 patients could be included in this study. Preoperative ASIA impairment scale showed positive correlation with postoperative outcome (p = 0.005). Patients with a favorable outcome (ASIA D and E) showed a statistically significant lower mean obliteration of the spinal canal by the hematoma with 46.4% (± 8%) in comparison to patients with an unfavorable outcome with 62.1% (± 6%, p = 0.001). A cut-off of 51% yielded a sensitivity and specificity for favorable outcome of 100% and 70% respectively (area under the ROC 0.93, p < 0.001).

CONCLUSION

Preoperative percentage of spinal canal obliteration is statistically significant lower in patients with favorable outcome in surgically treated patients with spontaneous spinal epidural hematoma.

A rare case of non-traumatic spinal epidural hematoma in lumbar region associated with apixaban therapy

Spontaneous spinal epidural hematoma (SSEH) is a very rare clinical entity with potential diagnostic difficulties and which can result in severe neurological deficit. The etiology of this rare condition is largely not known, but with potential predisposition in patients on anticoagulation medication. This includes the novel anticoagulants with direct inhibition of the factor Xa mechanism (DOACs). These medications are supposed to have more predictable pharmacokinetics with fewer severe haemorrhagic adverse events in comparison with standard warfarin therapy. However, in the last few years, an increasing number of case reports have been published of haemorrhage into the central nervous system. We present a case of non-traumatic spinal epidural hematoma in the lumbar region in a patient on chronic apixaban therapy. To the best of our knowledge, it is the first described SSEH in the lumbar region associated with apixaban therapy.

Unusual pediatric epidural arteriovenous fistula with venous ectasia presented with spontaneous spinal epidural hematoma: Case report

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is rare in children. Vascular malformation including arteriovenous fistulas and venous malformation is a rare cause of SSEH.

CASE DESCRIPTION

A 5-year-old girl presented with 2 episodes of SSEH at the upper thoracic spine and non-hemorrhagic episodes with spontaneous neurological recovery. Diagnostic study with MRI and spinal angiography demonstrated an unusual epidural arteriovenous fistula (AVF) with venous ectasia similar to venous malformation. She underwent embolization of the AVF with NBCA with mild transient neurological deterioration. Follow up angiography showed persistent occlusion of the embolized fistula and inconsistent visualization of another AVF to the patent venous ectasia.

CONCLUSIONS

This type of epidural AVF seems to be more common in children and tends to cause multiple neurologic episodes due to SSEH, venous expansion or thrombosis. Endovascular embolization with NBCA should be the first choice of treatment for this disease, unless emergent hematoma evacuation is necessary. Embolization should target at only the fistula site without significant penetration into the venous ectasia. Follow up is necessary for potential reappearance of AVF, even if AVF is occluded at the time of treatment. Time resolved MRI is useful to detect AVFs, thus for diagnosis and follow up of this disease.

Spontaneous Spinal Epidural Hematoma Associated With Apixaban Therapy: A Report of two Cases

Spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity that can result in severe neurological deficit and warrants emergent neurosurgical evaluation and management. The exact etiology of this entity remains unknown, but certain risk factors exist, including the use of anticoagulant medications. There are few published reports of the association of SSEH with direct factor Xa inhibitors. We aimed to present 2 cases of SSEH in patients on chronic apixaban therapy. To the best of our knowledge, there is only 1 other report of SSEH in the setting of apixaban therapy. A comparison between the cases suggests the importance of rapid recognition and management of SSEH in order to achieve favorable neurological outcomes.

Clinical Anatomy of the Extradural Neural Axis Compartment: A Literature Review

OBJECTIVE

The extradural neural axis compartment (EDNAC) is an adipovenous zone located between the meningeal and endosteal layers of the dura and has been minimally investigated. It runs along the neuraxis from the orbits down to the coccyx and contains fat, valveless veins, arteries, and nerves. In the present review, we have outlined the current knowledge regarding the structural and functional significance of the EDNAC.

METHODS

We performed a narrative review of the reported EDNAC data.

RESULTS

The EDNAC can be organized into 4 regional enlargements along its length: the orbital, lateral sellar, clival, and spinal segments, with a lateral sellar orbital junction linking the orbital and lateral sellar segments. The orbital EDNAC facilitates the movement of the eyeball and elsewhere allows limited motility for the meningeal dura. The major nerves and vessels are cushioned and supported by the EDNAC. Increased intra-abdominal pressure will also be conveyed along the spinal EDNAC, causing increased venous pressure in the spine and cranium. From a pathological perspective, the EDNAC functions as a low-resistance, extradural passageway that might facilitate tumor encroachment and expansion.

CONCLUSIONS

Clinicians should be aware of the extent and significance of the EDNAC, which could affect skull base and spine surgery, and have an understanding of the tumor spread pathways and growth patterns. Comparatively little research has focused on the EDNAC since its initial description. Therefore, future investigations are required to provide more information on this underappreciated component of neuraxial anatomy.

Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI-Two Medical Specialties Facing a Rare Dilemma

Spontaneous spinal epidural hematoma (SSEH) is a rare, albeit well-documented complication following thrombolysis treatment in ST elevation myocardial infarction (STEMI). A SSEH usually manifests with cervical pain and neurologic deficits and may require surgical intervention. In this case report, we present the first reported SSEH to occur following thrombolysis with reteplase. In this case, the SSEH manifested with cervical pain shortly after the patient emerged from his rescue percutaneous coronary intervention (PCI). Although magnetic resonance imaging reported spinal cord compression, the lack of neurologic symptoms prompted the treating clinicians to delay surgery. A dangerous dilemma emerged, as the usual antithrombotic regimen that was necessary to avoid stent thrombosis post-PCI, was also likely to exacerbate the bleeding. As a compromise, the patient only received aspirin as a single antiplatelet therapy. Ultimately, the patient responded well to conservative treatment, with the hematoma stabilizing a week later, without residual neurologic deficits. In conclusion, the conservative treatment of SSEH appears to be an acceptable option for carefully selected patients, but the risks of permanent neurologic deficits and stent thrombosis have to be weighted for each patient.

Rapid Recovery of Spontaneous Spinal Epidural Hematoma without Surgical Treatment: Case Report and Literature Review

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a relatively uncommon yet potentially disabling neurologic emergency. The classical presentation includes a severe acute attack, sometimes radiating pain at the back, interscapular, or neck areas, followed by neurologic deficits. The main treatment is surgical, and self-healing cases are rare.

CASE DESCRIPTION

A 17-year-old female was admitted to the neurosurgery department with neck pain, myasthenia of the limbs, and difficulty moving. Mild neck pain had developed 1 week prior with no obvious predisposing causes. The patient had suddenly suffered severe neck pain during normal walking and developed rapid paralysis of her limbs. There was no recent history of trauma, infection, or drug administration. Magnetic resonance imaging performed 1 hour after the onset of limb paralysis demonstrated a large spinal epidural hematoma that extended from C4 to C6. However, 9 hours after the initial onset of severe neck pain, her symptoms completely ceased. Magnetic resonance imaging demonstrated that the SSEH had nearly dissipated.

CONCLUSIONS

Most cases of SSEH with spontaneous resolution are located on the upper thoracic and cervical spine. Surgery is the standard of care for these patients but can occasionally be deferred if the patient demonstrates significant rapid improvement.

Spontaneous Spinal Epidural Hematoma from Rivaroxaban

Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.

Thoracic epidural haematoma due to a subclavian steal syndrome and secondary formed thoracic collateral circuits, coincidence or consequence: a case report

Despite profound diagnostics, the aetiology of spinal epidural haematoma (SEH) often remains unknown. In this case, diagnostics revealed an SEH at the fifth and sixth thoracic levels due to a subclavian steal syndrome with a tortuous vascular loop between the sixth thoracic intercostal artery and the costocervical arteries deriving from the left subclavian artery with plump arteries in the epidural space. The patient underwent decompression surgery and a percutaneous transluminal angioplasty. The patient showed good recovery at follow-up. The SEH was a result of secondary formed thoracic collateral circuits with epidural involvement due to a subclavian steal syndrome.