Spontaneous Spinal Epidural Hematoma During Pregnancy

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.

Spontaneous spinal epidural hemorrhage following disseminated intravascular coagulation resulting in paraplegia: a case report

CONTEXT

Spontaneous spinal epidural hemorrhage (SSEH) mostly presents as low back pain with or without a radiculopathy, and rarely with paraplegia or tetraplegia depending on the site and severity of spinal cord compression. We present here a case who had anemia and developed paraplegia following disseminated intravascular coagulation (DIC) due to a transfusion reaction.

FINDINGS

A 65-year-old lady presented with sudden onset chest pain radiating to nape of the neck followed by loss of sensations and power in legs few hours after a blood transfusion. Her past history was negative for diabetes mellitus, hypertension, coronary artery disease, or a bleeding disorder. Her blood pressure was 90/57 mmHg and she had a normal pulse, respiratory rate, and temperature. On neurological examination, she had no motor power and unevokable muscle stretch reflexes in the lower limbs. The sensations were intact till T₃ dermatome. The laboratory evaluation was suggestive of DIC. The magnetic resonance imaging showed a non-enhancing abnormal signal intensity area in the posterior epidural space, extending from CV₄ to LV₄ causing cervico-dorsal cord compression associated with cord edema. Following diagnosis, urgent decompressive surgery was carried out due to deteriorating neurological status. The patient was transfused with five bags of red cell concentrate, two bags of platelets, and four bags of fresh frozen plasma during the operation. The patient regained consciousness following operation, however, the neurological status did not improve. She, unfortunately, died on the third post-op day due to cardiac arrest.

CONCLUSION

SSEH is a rare cause of paraplegia. Early radiological diagnosis is crucial for timely neurosurgical management and saving patient from permanent neurological deficit or a fatal outcome.

Spontaneous Spinal Epidural Haematoma in a 34-week Pregnant Woman: A Case Report and Literature Review

Acute spontaneous spinal epidural haematoma is uncommon; however, it can result in permanent neurological damage if not promptly treated. It occurs very rarely during pregnancy. We report a case of acute spontaneous spinal epidural hematoma in a 34-year-old primigravida woman at 34 weeks’ gestation who presented with sudden back pain and paraplegia. Emergency spinal decompression surgery was done with the continuation of pregnancy. We discuss the presentation and management of the rare condition with a review of the literature.

Spontaneously Resolved Recurrent Cervical Epidural Hematoma in a 37-Week Primigravida

Study Design Case report. Objective To describe a patient with a recurrent spontaneous spinal epidural hematoma (SSEH) during pregnancy that had spontaneous remission. Methods A 27-year-old primigravida at 37 weeks' gestation suddenly felt a strong left shoulder pain without any trauma. She had a history of fenestration for a spontaneous cervical hematoma when she was 18 years old. An emergency magnetic resonance imaging revealed a recurrence of the cervical epidural hematoma at the C4-T1 level, but she had no paralysis. Results The patient subsequently underwent a cesarean section and delivered a healthy male infant. Her spinal epidural hematoma disappeared. Multislice computed tomography showed no evidence for a vascular malformation or tumor. Three years after the initial cesarean section, she underwent a second one and delivered another male infant. Conclusions We report on a rare case of recurrent SSEH during pregnancy with no neurologic deficits that was treated nonoperatively with close observation and resulted in spontaneous resolution. In such patients with no neurologic deficits, nonoperative management with close observation may be a reasonable alternative.

Non Traumatic Spinal Epidural Haematoma in a Woman with HELLP Syndrome: A Case Report

Spinal epidural haematomas (SEH) is a potentially reversible cause of spinal cord and nerve root compression which needs prompt surgical decompression for satisfactory neurological recovery. SEH occurs very rarely in pregnant woman with HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet levels). Most of the SEH cases reported in HELLP syndrome in the literature are due to iatrogenic interventions. We report a still rarer case of non traumatic spinal epidural haematoma in a pregnant woman with HELLP Syndrome.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns

OBJECTIVE

Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines.

METHODS

Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors.

RESULTS

In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks.

CONCLUSION

This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

Spontaneous cervical spinal epidural hematoma in the postpartum period

STUDY DESIGN

We present the case study of a 31-year-old lady who had a spontaneous cervical spinal epidural hematoma in the postpartum period and who presented with sudden onset of neck pain and lower limb weakness for which an emergency decompressive laminectomy was performed with neurological recovery.

OBJECTIVE

To report on the spontaneous spinal epidural hematoma in the postpartum period, which is a rare complication during pregnancy and requires early recognition and expedient intervention to prevent permanent neurological sequelae.

SUMMARY OF BACKGROUND DATA

This complication has been described only once previously in the postpartum period. The recovery of the patient described here highlights the importance of early recognition and surgical intervention.

METHODS

A case report of a spontaneous cervical spinal epidural haematoma in the postpartum period is presented and the pertinent literature is then reviewed.

RESULTS

The patient had neurological recovery at 1-year follow-up, although she required clean intermittent self-catheterization once daily for bladder dysfunction.

CONCLUSION

Early recognition and intervention for our patient allowed for neurological recovery with a spontaneous cervical spinal epidural hematoma in the postpartum period.

Spontaneous spinal epidural hematoma at the 16th week of a twin pregnancy

Spontaneous spinal epidural hematoma without discernable underlying conditions is a rare complication during pregnancy. We report a pregnant woman who developed the hematoma at 16 weeks of pregnancy; the earliest occurrence ever reported. A 36-year-old Japanese primipara with twins felt shoulder, neck and back pain at 16(+1) weeks with progressive quadriplegia. Magnetic resonance imaging revealed a mass in the C3-7 epidural space, compatible with a spinal epidural hematoma, and decompression was performed 9 h after symptom onset. Rehabilitation started and she gave birth abdominally to healthy twin infants at the 29th week. Motor, sensory and sphincter disturbances remained. This case demonstrates that spinal epidural hematoma can occur even without known underlying conditions and even at an early gestational age.

Spontaneous cervical epidural hematoma during pregnancy: case report and literature review

Spontaneous spinal epidural hematoma (SSEH) during pregnancy is rare and may result in permanent damage if not promptly treated. There were few studies discussing the etiology, presentation and treatment of SSEH during pregnancy. The authors describe a case of spontaneous cervical epidural hematoma during pregnancy, which was diagnosed by magnetic resonance imaging (MRI) and managed with surgical evacuation. A retrospective review of a case of spontaneous epidural hematoma of spine during pregnancy was performed. The clinical features, diagnoses, treatments and outcomes of all cases were analyzed. Precise diagnosis without delay and rapid surgical treatment are essential for the management of SSEH during pregnancy.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)

The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.

Postpartum spinal cord injury in a woman with HELLP syndrome

OBJECTIVE

To report a rare cause of spinal cord injury.

STUDY DESIGN

Case report.

CASE REPORT

A 36-year-old woman presented with acute onset of paresis of the upper and lower extremity (level C5, ASIA B) the day after delivering a healthy daughter (39 weeks' gestation). Prior to giving birth, she was admitted with gestational hypertension. Directly postpartum, blood pressure increased markedly, and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome was diagnosed. The next day, tetraplegia developed. Magnetic resonance imaging showed multiple epidural and subdural hematomas in the cervical and thoracic spinal canal extending from C2 to T8, with displacement and compression of the cord. Three weeks after treatment with intravenous labetalol, she made a significant recovery (level T1, ASIA D).

CONCLUSIONS

This rare cause of spinal cord injury shows the importance of closely monitoring pregnant patients with hypertension complicated with HELLP syndrome both pre- and postpartum.

[Spontaneous spinal epidural haematoma during pregnancy]

Spontaneous spinal epidural haematomas are quite rare. We report here the case of a 27-year-old woman, without previous history of relevant medical disorder, who presented with acute paraplegia at 36 weeks of gestation. MRI performed in emergency revealed a T8 epidural haematoma. The management consisted in an emergency Caesarean section under general anaesthesia, followed immediately by a T8 laminectomy allowing the spinal cord decompression 14 hours after the first symptoms. Neurologic recovery was rapid and complete, except for bladder dysfunction persisting one month later. Spontaneous spinal epidural haematomas require a prompt diagnosis because neurologic prognosis essentially depends on the interval of time between onset of symptoms and surgical decompression. Obstetrical management especially depends on the term of pregnancy. For the anaesthesiologist, the difficulty is the management of both pregnant condition (full stomach general anaesthesia) and spinal cord compression (maintenance of spinal cord perfusion pression and limitation of ischaemia and oedema).