Cauda equina syndrome caused by delayed traumatic spinal subdural haematoma

Postoperative spinal subdural hygroma without incidental durotomy: illustrative cases

BACKGROUND

Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.

OBSERVATIONS

The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the “flying bat” sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.

LESSONS

Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.

Delayed Development of Spinal Subdural Hematoma Following Cranial Trauma: A Case Report and Review of the Literature

BACKGROUND

Spinal subdural hematomas (SDHs) have been reported secondary to direct trauma or iatrogenic causes associated with coagulopathies. Spinal SDHs found after the development of acute intracranial SDHs, without any evidence of trauma to the spine, are extremely rare. In addition to this rare presentation, there is a lack of consensus regarding whether surgical decompression is the ideal treatment strategy. Depending on the extent of SDH within the spinal canal, surgical decompression may be difficult where diffuse hematoma within the intradural space requires multilevel decompression for treatment.

CASE DESCRIPTION

A 46-year-old man initially presented with an acute cranial SDH following isolated head trauma. After a period of full recovery, he developed delayed lower extremity paraparesis secondary to the formation of a thoracolumbar SDH. This hematoma coincided with resolution of the cranial SDH and likely was due to redistribution of blood from the cranial subdural space into the spinal canal. Given the diffuse multilevel nature of the spread of hematoma and lack of a focal area of compression, he was managed conservatively. He demonstrated small signs of neurologic improvement over several days and regained considerable strength over the following several weeks.

CONCLUSIONS

This report demonstrates a very rare occurrence of a traumatic intracranial SDH migrating into the thoracic and lumbar spine. This case also highlights that despite acute neurologic deficits, conservative management may be a feasible strategy that can result in recovery of neurologic function.

Differential diagnosis and treatment of acute cauda equina syndrome in the human immunodeficiency virus positive patient: a case report and review of the literature

BACKGROUND

Acute cauda equina syndrome is an uncommon but significant neurologic presentation due to a variety of underlying diseases. Anatomical compression of nerve roots, usually by a lumbar disk hernia is a common cause in the general population, while inflammatory, neoplastic, and ischemic causes have also been recognized. Among human immunodeficiency virus (HIV) infected patients with acquired immunodeficiency syndrome, infectious causes are encountered more frequently, the most prevalent of which are: cytomegalovirus, herpes simplex virus 1/2, varicella zoster virus, and Mycobacterium tuberculosis infections. Studies of cauda equina syndrome in well-controlled HIV infection are lacking. We describe such a case of cauda equina syndrome in a well-controlled HIV-infected patient, along with a brief review of the literature regarding the syndrome's diagnosis and treatment in individuals with HIV infection.

CASE PRESENTATION

A 36-year-old Greek male, HIV-positive patient presented with perineal and left hemiscrotal numbness, lumbar pain, left-sided sciatica, and urinary incontinence. Magnetic resonance imaging of the patient's lumbar spine revealed intrathecal migration of a fragment from an intervertebral lumbar disk exerting pressure on the cauda equina. A cerebrospinal fluid examination, brain computed tomography scan, spine magnetic resonance imaging, and serological test results were negative for central nervous system infections. Our patient underwent emergency neurosurgical spinal decompression, which resolved most symptoms, except for mild urinary incontinence.

CONCLUSIONS

Noninfectious etiologies may also cause cauda equina syndrome in HIV-infected individuals, especially in well-controlled disease under antiretroviral therapy. Prompt recognition and treatment of the underlying cause is important to minimize residual symptoms. Targeted antimicrobial chemotherapy is used to treat infectious causes, while prompt surgical decompression is favored for anatomical causes of cauda equina syndrome in the HIV-infected patient.

Simultaneous Spinal and Intracranial Chronic Subdural Hematoma Cured by Craniotomy and Laminectomy: A Video Case Report

Simultaneous spinal and intracranial chronic subdural hematoma (CSDH) is a rare entity. A 67-year-old man visited our hospital due to headache after diving into a river 2 weeks before. Non-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) revealed bilateral intracranial CSDH. The bilateral CSDH was evacuated and his symptoms improved. Three days after craniotomy, he complained of sensory disturbance on his buttocks. Lumbar MRI showed a space-occupying lesion behind the thecal sac at L5. CT with myelography showed a subdural mass lesion; there was no communication with the subarachnoid space. Fourteen days after craniotomy, L5 laminectomy was performed and the dura mater was incised carefully. The video shows that a liquid hematoma similar to the intracranial CSDH flowed out, followed by cerebrospinal fluid. His symptoms improved after the operation and the hematoma did not recur. This is a rare condition of spinal CSDH demonstrated by neuroimaging and intraoperative video.

Spinal Subdural Hematoma Associated with Intracranial Subdural Hematoma

The simultaneous occurrence of an intracranial and a spinal subdural hematoma (SDH) is rare. We describe a case of cranial SDH with a simultaneous spinal SDH. An 82-year-old woman visited the emergency room because of drowsiness and not being able to walk 6 weeks after falling down. A neurological examination showed a drowsy mentality. Brain computed tomography showed bilateral chronic SDH with an acute component. The patient underwent an emergency burr-hole trephination and hematoma removal. She exhibited good recovery after the operation. On the fourth postoperative day, she complained of low-back pain radiating to both lower limbs, and subjective weakness of the lower limbs. Spine magnetic resonance imaging revealed a thoracolumbosacral SDH. A follow-up spinal magnetic resonance imaging study that was performed 16 days later showed a significant decrease in the size of the spinal SDH. We discuss the pathogenesis of this simultaneous occurrence of spinal and cranial SDH.

Significantly prolonged spinal anesthesia with the addition of dexamethasone: a case report

The purpose of the study is to highlight that prolonged blocks with spinal anesthesia are not usually due to neurologic defects. Consent for data publication was obtained. A 35-year-old female patient with right upper tibial chondrosarcoma was planned to undergo excision and reconstruction with a free vascularized fibular graft. The patient had no significant medical history. We gave spinal anesthesia, which is to be continued with general anesthesia after regression of the sensory level. After 3 hours, we evaluated the patient for the second time to find sensory block at T10 level. It was decided to carry out these evaluations hourly and wait for general anesthesia. Ten hours after the spinal anesthesia, the sensory block was still at T10 level. After 13 hours, the surgical procedure was finished, and the sensory block was still at T10 level and the motor block according to the Bromage scale remained at grade 4. A computed tomography was performed and did not reveal signs of spinal compression, spinal canal stenosis, or other anomalies (magnetic resonance imaging was unavailable). A complete motor and sensory recovery from the spinal block was observed 20 hours after spinal anesthesia. We present a case of major microscopic surgery done over 13 hours with a single shot of spinal anesthesia in a 35-year-old female patient. Complete recovery of sensory and motor blocks has been after 20 hours. We also review other cases of unusually prolonged spinal blocks and the possible differential diagnosis for that.

Acute spinal subdural hematoma after vigorous back massage: a case report and review of literature

STUDY DESIGN

A case report and review of literature.

OBJECTIVE

We report on a patient with traumatic spinal subdural hematoma after vigorous back massage while on vacation.

SUMMARY OF BACKGROUND DATA

Traumatic spinal subdural hematoma is extremely rare, and to our knowledge, this is the first case reported after violent back massage. We emphasize a high index of suspicion for early recognition and treatment for a good neurological recovery.

METHODS

A 41-year-old male was brought to our hospital with severe back pain, motor and sensory impairments of the bilateral lower extremities, and urinary dysfunction after vigorous back massage. Magnetic resonance images revealed an acute spinal subdural hematoma in the thoracolumbar region. After careful monitoring of his neurological status, the patient was successfully managed with conservative treatment.

RESULTS

After 2 weeks of hospitalization, complete motor power recovery was achieved with only minor sensory deficit. At a follow-up of more than 12 months, the patient has no residual neurological deficits.

CONCLUSION

Spinal subdural hematoma secondary to physical trauma is quite rare. This case brings new information that traumatic spinal subdural hematoma can be caused by violent massage.

LEVEL OF EVIDENCE

N/A.

Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation?

Object

Spinal subdural hematomas (SDHs) are rare and some are concomitant with intracranial SDH. Their pathogenesis and etiology remain to be elucidated although their migration from the intracranial space has been suggested. The authors postulated that if migration plays a major role, patients with intracranial SDH may harbor asymptomatic lumbar SDH. The authors performed a prospective study on the incidence of spinal SDH in patients with intracranial SDH to determine whether migration is a key factor in their concomitance.

Methods

The authors evaluated lumbar MR images obtained in 168 patients (125 males, 43 females, mean age 75.6 years) with intracranial chronic SDH to identify cases of concomitant lumbar SDH. In all cases, the lumbar MRI studies were performed within the 1st week after surgical irrigation of the intracranial SDH.

Results

Of the 168 patients, 2 (1.2%) harbored a concomitant lumbar SDH; both had a history of trauma to both the head and the hip and/or lumbar area. One was an 83-year-old man with prostate cancer and myelodysplastic syndrome who suffered trauma to his head and lumbar area in a fall from his bed. The other was a 70-year-old man who had hit his head and lumbar area in a fall. Neither patient manifested neurological deficits and their hematomas disappeared under observation. None of the patients with concomitant lumbar SDH had sustained head trauma only, indicating that trauma to the hip or lumbar region is significantly related to the concomitance of SDH (p < 0.05).

Conclusions

As the incidence of concomitant lumbar and intracranial chronic SDH is rare and both patients in this study had sustained a direct impact to the head and hips, the authors suggest that the major mechanism underlying their concomitant SDH was double trauma. Another possible explanation is hemorrhagic diathesis and low CSF syndrome.

Migration of traumatic intracranial subdural hematoma to lumbar spine causing radiculopathy

Background:

There have been rare reports of intracranial subdural hematoma (SDH) that migrated into the spine. All previous cases have been surgically managed and in this case report, we describe the first case of conservatively managed spinal hematoma secondary to migratory intracranial SDH.

Case Description:

A 26-year-old male presented with a left tentorial SDH after blunt trauma. He was conservatively managed and discharged home. He presented 8 days later with worsening lower back pain that was found to be secondary to a spinal SDH.

Conclusion:

Spinal hematomas can be a serious sequelae of migrated intracranial hematomas. Tentorial and other caudally located intracranial hematomas may be more prone to this phenomenon.

Spinal subdural hemorrhage in abusive head trauma: a retrospective study

PURPOSE

To compare the relative incidence, distribution, and radiologic characteristics of spinal subdural hemorrhage after abusive head trauma versus that after accidental trauma in children.

MATERIALS AND METHODS

This study received prior approval from the Human Subjects Protection Office. Informed consent was waived. This study was HIPAA compliant. Two hundred fifty-two children aged 0-2 years treated for abusive head trauma at our institute between 1997 and 2009 were identified through retrospective chart review. A second group of 70 children aged 0-2 years treated at our institute for well-documented accidental trauma between 2003 and 2010 were also identified through retrospective chart review. All clinical data and cross-sectional imaging results, including computed tomographic and magnetic resonance imaging of the brain, spine, chest, abdomen, and pelvis, were reviewed for both of these groups. A Fisher exact test was performed to assess the statistical significance of the proportion of the spinal canal subdural hemorrhage in abusive head trauma versus that in accidental trauma.

RESULTS

In the abusive head trauma cohort, 67 (26.5%) of 252 children had evaluable spinal imaging results. Of these, 38 (56%) of 67 children had undergone thoracolumbar imaging, and 24 (63%) of 38 had thoracolumbar subdural hemorrhage. Spinal imaging was performed in this cohort 0.3-141 hours after injury (mean, 23 hours ± 27 [standard deviation]), with 65 (97%) of 67 cases having undergone imaging within 52 hours of injury. In the second cohort with accidental injury, only one (1%) of 70 children had spinal subdural hemorrhage at presentation; this patient had displaced occipital fracture. The comparison of incidences of spinal subdural hemorrhage in abusive head trauma versus those in accidental trauma was statistically significant (P < .001).

CONCLUSION

Spinal canal subdural hemorrhage was present in more than 60% of children with abusive head trauma who underwent thoracolumbar imaging in this series but was rare in those with accidental trauma.

A rare, high cervical traumatic spinal subdural hematoma

Spinal subdural hematomas (SSDH) are rare lesions occurring in association with a wide variety of conditions, including anticoagulation, coagulation disorders, spinal anesthesia, lumbar puncture, spinal tumors and vascular malformations. SSDH resulting from trauma are the exception. We present a 62-year-old woman with a rare post-traumatic focal SSDH at C1 with bulbomedullary compression, treated successfully with surgery. A review of the literature revealed 26 patients with traumatic SSDH. The aim of this report is to describe the clinical presentation, imaging characteristics and management of traumatic SSDH. The controversial pathogenesis is also discussed.

Acute cervical spinal subdural hematoma not related to head injury

We report an extremely rare case of traumatic cervical spinal subdural hematoma not related to intracranial injury. There has been no report on traumatic cervical spinal subdrual hematoma not related to intracranial injury. A 27-year-old female patient was admitted to our emergency room due to severe neck pain and right arm motor weakness after car collision. On admission, she presented with complete monoplegia and hypoesthesia of right arm. Magnetic resonance imaging (MRI) revealed subdural hematoma compressing spinal cord. Lumbar cerebrospinal fluid (CSF) analysis revealed 210,000 red blood cells/mm(3). She was managed conservatively by administrations of steroid pulse therapy and CSF drainage. Her muscle power of right arm improved to a Grade III 16 days after admission. Follow-up MRI taken 16th days after admission revealed almost complete resolution of the hematoma. Here, the authors report a traumatic cervical spinal SDH not associated with intracranial injury.

Traumatic subdural hematoma of the thoraco-lumbar junction of spinal cord

BACKGROUND

Spinal subdural hematoma (SSDH) is an exceedingly uncommon and potentially neurologically devastating condition. Recognition of blood products in magnetic resonance imaging is a very important clue for the diagnosis of SSDH. It is generally agreed that prompt surgical evacuation should be performed before irreversible damage to the spinal cord occurs. However, conservative treatment still plays a role in the management of SSDH.

OBJECTIVES

To describe the clinical presentation, characteristic MRI findings, and treatment of traumatic SSDH.

METHODS

A case of traumatic SSDH at the thoraco-lumbar junction.

RESULTS

Magnetic resonance imaging findings of high signal intensity lesion in both T1 and T2 sequences suggest the possibility of subdural hematoma although it may be mistaken for tumorlike cystic lesion of the cord. Although there is a place for conservative treatment of subdural hematoma, we believe that rapid surgical drainage of the subdural hematoma will be associated with the best prognosis especially in the cervical, thoracic, and thoraco-lumbar junctions of the spinal cord.

CONCLUSIONS

Rapid surgical drainage of traumatic SSDH affecting the thoraco-lumbar junction of the cord will be associated in most of the cases with rapid neurologic recovery.

A Case Report of an Uncommon Cause of Cauda Equina Symptoms

OBJECTIVE

This case report discusses a patient who presented with right-sided buttock pain of apparently uncomplicated mechanical origin that was eventually diagnosed as a primary Ewing sarcoma/primitive neuroectodermal tumor of the sacrum.

CLINICAL FEATURES

A 32-year-old male full-time student presented for care with right-sided buttock pain.

INTERVENTION AND OUTCOME

After examination, the patient was referred to his general practitioner for urgent magnetic resonance imaging, the report revealed no explanation for the presenting symptoms. After further imaging and biopsy, an eventual diagnosis of Ewing sarcoma/primitive neuroectodermal tumor was reached. The patient died 12 months later.

CONCLUSION

This case highlights a nondiscal cause for cauda equina symptoms. It emphasizes potential diagnostic complexities that may present due to preconceptions based upon the probability of symptoms being related to a specific disease process.

Cauda equina syndrome after induction of spinal anesthesia

In this report the authors present a case of cauda equina syndrome that developed following induction of spinal anesthesia in a patient who had no apparent preexisting bleeding abnormality. An acute subdural hematoma caused the syndrome and was believed to have resulted from direct vascular trauma during administration of spinal anesthesia or from vascular trauma combined with thrombocytopenia in the postoperative period.

Subacute spinal subdural hematoma after spontaneous resolution of cranial subdural hematoma: causal relationship or coincidence? Case report

The etiopathogenesis of traumatic spinal subdural hematoma (SSH) is uncertain. Unlike the supratentorial subdural space, no bridging veins traverse the spinal subdural space. The authors describe a case of subacute SSH that occurred after spontaneous resolution of traumatic intracranial SDH and suggest a causal relationship between the two. A 23-year-old woman suffered an acute intracranial SDH after a snowboarding accident. There was no clinical or radiological evidence of spine injury. Conservative management of the supratentorial SDH resulted in spontaneous radiologically documented resolution with redistribution of blood in the subdural space. Four days after the injury, the patient started noticing new onset of mild low-back pain. The pain progressively worsened. Magnetic resonance imaging of the lumbosacral spine 10 days after the original injury revealed a large L4-S2 SDH. Ten days after the original injury, bilateral L5-S1 laminotomy and drainage of the subacute spinal SDH were performed. The patient experienced immediate pain relief. The authors hypothesize that in some cases spinal SDH may be related to redistribution of blood from the supratentorial subdural space.

Traumatic spinal subdural hematoma with spontaneous resolution

STUDY DESIGN

A case report with a literature review is presented.

OBJECTIVE

To describe and review the clinical presentations, characteristic findings from imaging studies, and treatment of traumatic spinal subdural hematoma.

SUMMARY OF BACKGROUND DATA

Traumatic spinal subdural hematoma is uncommon, and only eight cases have been reported in the literature. Concomitant intracranial and spinal subdural hematoma in the same patient has not been well studied.

METHODS

A case of concomitant spinal and intracranial subdural hematoma is reported as well as a review of the literature.

RESULTS

Including our patient, we found that five of the nine patients with traumatic spinal subdural hematoma also had intracranial hematoma. We hypothesize that the mechanism of traumatic spinal subdural hematoma may be associated with intracranial events. Recognition of blood products in magnetic resonance imaging scans is important to distinguish spinal subdural hematoma from other spinal lesions. It is generally agreed that prompt laminectomy with evacuation of hematoma should be performed before irreversible damage to the spinal cord occurs. However, including our patient, three of the nine reported cases with thoracic or lumbar subdural hematoma resolved spontaneously with conservative treatment.

CONCLUSIONS

This 12-year-old boy illustrated the rapid spontaneous resolution of traumatic subdural hematoma in both left hemisphere and lumbar spine with conservative treatment. This report suggests a possible role of conservative management for traumatic lumbar subdural hematoma, especially when the patients already have neurologic recovery.