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Nakamura S, Yoshida S, Matsuda H, Yahata T, Inokuchi K, Maru T, Ogihara S, Saita K, Oya S. Ultraearly Hematoma Evacuation (<12 Hours) Associated with Better Functional Outcome in Patients with Symptomatic Spontaneous Spinal Epidural Hematoma. World Neurosurg 2023; 171:e859-e863. [PMID: 36627018 DOI: 10.1016/j.wneu.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Sho Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Hiromi Matsuda
- Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Tadashi Yahata
- Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Inokuchi
- Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takanori Maru
- Orthopedic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Satoshi Ogihara
- Orthopedic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kazuo Saita
- Orthopedic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
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Deer TR, Russo MA, Grider JS, Pope J, Rigoard P, Hagedorn JM, Naidu R, Patterson DG, Wilson D, Lubenow TR, Buvanendran A, Sheth SJ, Abdallah R, Knezevic NN, Schu S, Nijhuis H, Mehta P, Vallejo R, Shah JM, Harned ME, Jassal N, Gonzalez JM, Pittelkow TP, Patel S, Bojanic S, Chapman K, Strand N, Green AL, Pahapill P, Dario A, Piedimonte F, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation. Neuromodulation 2022; 25:1-34. [PMID: 35041578 DOI: 10.1016/j.neurom.2021.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. MATERIALS AND METHODS Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. RESULTS This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. CONCLUSIONS The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA.
| | - Marc A Russo
- Hunter Pain Specialists, Newcastle, New South Wales, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Philippe Rigoard
- Department of Spine Surgery and Neuromodulation, PRISMATICS Lab, Poitiers University Hospital, Poitiers, France
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ramana Naidu
- California Orthopedics & Spine, Larkspur, CA, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | | | - Samir J Sheth
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Davis, CA, USA
| | - Rany Abdallah
- Center for Interventional Pain and Spine, Milford, DE, USA
| | - N Nick Knezevic
- Department of Anesthesiology and Surgery at University of Illinois, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Stefan Schu
- Leitender Arzt Neuromodulation, Neurochirurgie, Sana Kliniken Duisburg GmbH, Duisburg, Germany
| | - Harold Nijhuis
- Department of Anesthesiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Michael E Harned
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Jose Manuel Gonzalez
- Hospital Clínico Universitario Virgen de la Victoria, Servicio Andaluz de Salud, Málaga, Spain
| | - Thomas P Pittelkow
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Kenneth Chapman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, The Pain and Spine Institute of New York, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, England, UK
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alessandro Dario
- Department of Neurosurgery, ASST Settelaghi, Insubria University, Varese, Italy
| | | | - Robert M Levy
- International Neuromodulation Society, Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Musha Y, Kinjo S, Ishimine Y, Takesue Y, Sakamoto T, Ito K. Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention. J Clin Neurosci 2021; 86:242-246. [PMID: 33775335 DOI: 10.1016/j.jocn.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/30/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.
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Affiliation(s)
- Yoshiro Musha
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
| | - Sumito Kinjo
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Youhei Ishimine
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Yuya Takesue
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Tetsuo Sakamoto
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Keisuke Ito
- Department of Neurosurgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
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Puerperal ventral epidural hematoma after epidural labor analgesia. Int J Obstet Anesth 2017; 31:100-104. [PMID: 28499552 DOI: 10.1016/j.ijoa.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/12/2017] [Accepted: 03/25/2017] [Indexed: 11/20/2022]
Abstract
Serious complications in obstetric anesthesia are a rare occurrence. High neuraxial block, respiratory arrest in labor and delivery, and an unrecognized spinal catheter are among the most frequently reported serious complications. A serious complication occurs in approximately 1:3000 obstetric patients. Neuraxial hematoma after obstetric epidural analgesia or anesthesia is extremely rare. We present a case of a puerperal spinal epidural hematoma following epidural labor analgesia. The patient presented with foot drop, which resolved after conservative treatment. We reviewed the epidemiology, clinical manifestations and treatment options for this rare complication.
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Wang M, Zhou P, Jiang S. Clinical Features, Management, and Prognostic Factors of Spontaneous Epidural Spinal Hematoma: Analysis of 24 Cases. World Neurosurg 2017; 102:360-369. [PMID: 28288922 DOI: 10.1016/j.wneu.2017.02.058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency. It presents as acute spinal cord compression and usually requires surgical decompression. The patients who will benefit most from decompression surgery are unknown, and the factors associated with prognosis remain controversial. The purpose of our study was to identify the clinical features, treatments, and main factors related to the prognosis of SSEH. METHODS We reviewed the records of 24 patients treated for SSEH from September 2010 to January 2016 at West China Hospital. Clinical features, radiologic images, treatment methods, and clinical outcomes were reviewed retrospectively. To ascertain which factors were related to outcomes, statistical analysis was performed. RESULTS Among 24 patients, 19 presented with severe initial neurologic deficits (American Spinal Injury Association grade A-C) underwent decompressive surgery, and the remaining patients (initial American Spinal Injury Association grade D or E) received conservative treatment. Among the 19 patients in the operation group, seven (36.8%) had good outcomes, whereas 12 (63.2%) had poor outcomes. All patients in the conservative group had good outcomes. CONCLUSIONS SSEH is a rare but serious illness. It is more likely that SSEH arises from a ruptured internal vertebral venous plexus. The initial neurologic status is the determining factor influencing the treatment method and clinical outcome. The number of involved segments cannot be used to decide the treatment method or predict prognosis. Patients with shorter operative intervals appear to have better neurologic recovery.
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Affiliation(s)
- Mengmeng Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Peizhi Zhou
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shu Jiang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Siasios ID, Vakharia K, Gibbons KJ, Dimopoulos VG. Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome. Surg Neurol Int 2016; 7:S664-S667. [PMID: 27843682 PMCID: PMC5054634 DOI: 10.4103/2152-7806.191073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 12/22/2022] Open
Abstract
Background: Iatrogenic or spontaneous spinal hematomas are rarely seen and present with multiple symptoms that can be difficult to localize. Most spontaneous spinal hematomas are multifactorial, and the pathophysiology is varied. Here, we present a case of a scattered, multicomponent, combined subdural and epidural spinal hematoma that was managed conservatively. Case Description: A 38-year-old woman came to the emergency department (ED) complaining of severe neck and back pain. She had undergone a caesarean section under epidural anesthesia 4 days prior to her arrival in the ED. She was placed on heparin and then warfarin to treat a pulmonary embolism that was diagnosed immediately postpartum. Her neurological examination at presentation demonstrated solely the existence of clonus in the lower extremities and localized cervical and low thoracic pain. In the ED, the patient's international normalized ratio was only mildly elevated. Spinal magnetic resonance imaging revealed a large thoracolumbar subdural hematoma with some epidural components in the upper thoracic spine levels. Spinal cord edema was also noted at the T6-T7 vertebral level. The patient was admitted to the neurosurgical intensive care unit for close surveillance and reversal of her coagulopathy. She was treated conservatively with pain medication, fresh frozen plasma, and vitamin K. She was discharged off of warfarin without any neurological deficit. Conclusions: Conservative management of spinal hematomas secondary to induced coagulopathies can be effective. This case suggests that, in the face of neuroimaging findings of significant edema and epidural blood, the clinical examination should dictate the management, especially in such complicated patients.
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Affiliation(s)
- Ioannis D Siasios
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Kevin J Gibbons
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
| | - Vassilios G Dimopoulos
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA; Department of Neurosurgery, Kaleida Health, Buffalo, New York, USA
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Goyal G, Singh R, Raj K. Anticoagulant induced spontaneous spinal epidural hematoma, conservative management or surgical intervention—A dilemma? J Acute Med 2016. [DOI: 10.1016/j.jacme.2016.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
Central nervous system hemorrhage is an uncommon and potentially devastating event in hemophiliacs, with an incidence of 2-8%. Intraspinal hematomas account for 8.5% of CNS hemorrhages in patients with factor VIII or IX deficiencies. Although most reported cases in this population are secondary to trauma, there are a few reports of spontaneous hemorrhage. We present a case of spontaneous spinal epidural hematoma (SSEH) in a child with Hemophilia B, factor IX deficiency, and review the relevant management strategies.
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Kim T, Lee CH, Hyun SJ, Yoon SH, Kim KJ, Kim HJ. Clinical Outcomes of Spontaneous Spinal Epidural Hematoma : A Comparative Study between Conservative and Surgical Treatment. J Korean Neurosurg Soc 2012; 52:523-7. [PMID: 23346323 PMCID: PMC3550419 DOI: 10.3340/jkns.2012.52.6.523] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 09/07/2012] [Accepted: 12/18/2012] [Indexed: 12/17/2022] Open
Abstract
Objective The incidence of spontaneous spinal epidural hematoma (SSEH) is rare. Patients with SSEH, however, present disabling neurologic deficits. Clinical outcomes are variable among patients. To evaluate the adequate treatment method according to initial patients' neurological status and clinical outcome with comparison of variables affecting the clinical outcome. Methods We included 15 patients suffered from SSEH. Patients were divided into two groups by treatment method. Initial neurological status and clinical outcomes were assessed by the American Spinal Injury Association (ASIA) impairment scale. Also sagittal hematoma location and length of involved segment was analyzed with magnetic resonance images. Other factors such as age, sex, premorbid medication and duration of hospital stay were reviewed with medical records. Nonparametric statistical analysis and subgroup analysis were performed to overcome small sample size. Results Among fifteen patients, ten patients underwent decompressive surgery, and remaining five were treated with conservative therapy. Patients showed no different initial neurologic status between treatment groups. Initial neurologic status was strongly associated with neurological recovery (p=0.030). Factors that did not seem to affect clinical outcomes included : age, sex, length of the involved spinal segment, sagittal location of hematoma, premorbid medication of antiplatelets or anticoagulants, and treatment methods. Conclusion For the management of SSEH, early decompressive surgery is usually recommended. However, conservative management can also be feasible in selective patients who present neurologic status as ASIA scale E or in whom early recovery of function has initiated with ASIA scale C or D.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Spontaneous Spinal Epidural Hematoma: A Case Report and Literature Review. J Emerg Med 2012; 42:e31-4. [DOI: 10.1016/j.jemermed.2008.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 06/12/2008] [Accepted: 08/02/2008] [Indexed: 11/24/2022]
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Fedor M, Kim ES, Ding K, Muizelaar JP, Kim KD. Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature. KOREAN JOURNAL OF SPINE 2011; 8:272-82. [PMID: 26064145 PMCID: PMC4461739 DOI: 10.14245/kjs.2011.8.4.272] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 12/20/2011] [Accepted: 01/05/2012] [Indexed: 12/26/2022]
Abstract
Objectives The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits. Methods Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases. Results Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients. Conclusion We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.
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Affiliation(s)
- Mark Fedor
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Eric S Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kai Ding
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, USA
| | - J Paul Muizelaar
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
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Hematoma epidural cervical yatrogénico. Presentación de un caso clínico y revisión de la literatura. Neurocirugia (Astur) 2011. [DOI: 10.1016/s1130-1473(11)70029-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Braga MHV, Brandão RACS, Carvalho GTCD, Santos CD, Abreu MSD. Conservative treatment of large spontaneous spinal extradural hematoma. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 68:132-134. [PMID: 20339669 DOI: 10.1590/s0004-282x2010000100027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Aoki Y, Yamagata M, Shimizu K, Ikeda Y, Nakajima F, Ohtori S, Takahashi K. An unusually rapid spontaneous recovery in a patient with spinal epidural hematoma. J Emerg Med 2009; 43:e75-9. [PMID: 19892504 DOI: 10.1016/j.jemermed.2009.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 08/10/2009] [Accepted: 08/30/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spontaneous epidural hematoma is a rare condition, which usually requires urgent surgical treatment. OBJECTIVES To report two cases of spontaneous epidural hematoma, one of which was treated conservatively, and the other surgically, and discuss the possibility of unusual spontaneous recovery and treatment decision-making. CASE REPORT We encountered 2 patients with spontaneous spinal epidural hematoma, both of whom were taking an anti-platelet agent, producing severe paraplegia. One patient with a hematoma at C2-T3 experienced a rapid neurological recovery while a magnetic resonance imaging scan was being performed. A complete resolution of the hematoma and complete neurological recovery ensued without surgical intervention. A second patient with a hematoma at T10-12 showed no neurological recovery up to the time emergency surgery started and was treated surgically by T10-12 laminectomy and excision of the hematoma. Neurological function returned to normal in both patients. CONCLUSION The occurrence of spontaneous recovery in some patients makes the decision for surgery difficult. Emergency physicians need to be aware of the possibility of spontaneous rapid neurological recovery in patients with spinal epidural hematoma. To avoid unnecessary surgery in patients who will spontaneously have neurological recovery, neurological evaluations need to be repeatedly performed up to the time the emergency surgery begins. However, unfortunately, there is no diagnostic tool at present to identify the patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results, therefore, conservative treatment should be prescribed only for those patients who exhibit improving neurological signs early in the clinical course.
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Affiliation(s)
- Yasuchika Aoki
- Department of Orthopedic Surgery, Chiba Rosai Hospital, Ichihara, Chiba, Japan
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Deer TR, Stewart CD. Complications of Spinal Cord Stimulation: Identification, Treatment, and Prevention. PAIN MEDICINE 2008. [DOI: 10.1111/j.1526-4637.2008.00444.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Matsumura A, Namikawa T, Hashimoto R, Okamoto T, Yanagida I, Hoshi M, Noguchi K, Takami M. Clinical management for spontaneous spinal epidural hematoma: diagnosis and treatment. Spine J 2008; 8:534-7. [PMID: 17434807 DOI: 10.1016/j.spinee.2007.01.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Revised: 01/20/2007] [Accepted: 01/23/2007] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spontaneous spinal epidural hematoma (SSEH) is a very rare condition, so there were few studies assessing the management criteria of SSEH. PURPOSE To assess the differential diagnosis and clinical results of treatment for SSEH. STUDY DESIGN A retrospective chart and radiograph review of the patients with SSEH. PATIENT SAMPLE Seven consecutive patients with SSEH who were treated in our institute. OUTCOME MEASURES Differential diagnosis, severity of the paresis, and treatment selection were assessed preoperatively and postoperatively. METHODS We assessed the relationship between the following parameters and clinical results: (1) the initial symptoms, (2) imaging diagnosis of magnetic resonance imaging (MRI), (3) treatment selection (conservative or surgical treatment), (4) the interval of surgery, and (5) the severity of paresis using ASIA impairment scale (AIS) grading. RESULTS In all patients, the symptoms at onset were severe neck and back pain. MRI showed isointensity to the spinal cord in the T1-weighted view and iso- or high intensity in the T2-weighted view. A solid pattern in MRI was shown in 4 patients, and a mosaic pattern was shown in 3 patients. Decompression was performed in five cases, and spontaneous recovery appeared in two cases. The mean interval time for operation was 29.8 hours. The severity of paresis was grade B in 3 cases and grade C in 4 cases at onset. These cases recovered to become grade E in 3 cases and grade D in 4 cases. Neurological deficits were present in two patients with conservative therapy and in two patients with a long interval for operation. CONCLUSIONS Precise diagnosis without delay and rapid surgical treatment are essential for the management of SSEH.
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Affiliation(s)
- Akira Matsumura
- Department of Orthopaedic Surgery, Yodogawa Christian Hospital, Osaka City, Japan.
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Fok WM, Sun LK, Wong NM, Lau PY, Cheung HM. Spontaneous spinal epidural haematoma in a 15-month-old boy presenting with a wry neck: a case report. J Orthop Surg (Hong Kong) 2007; 15:373-5. [PMID: 18162690 DOI: 10.1177/230949900701500327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 15-month-old boy presented with a 2-day history of a wry neck (bent to the left side) with no definite trauma. He had bilateral upper limb weakness and was afebrile, conscious, and stable. There was no spontaneous movement in both upper limbs. Magnetic resonance imaging of the cervical and thoracic spine demonstrated an extensive spontaneous spinal epidural haematoma from C3 to T8. 23 hours after admission, the patient underwent an emergency right-sided C3 to T8 hemi-laminectomy and haematoma evacuation. The patent's strength gradually recovered and he attained full power 3 weeks after operation. Spontaneous spinal epidural haematoma is a rare disease in children. A high index of suspicion is essential for its effective management as the interval to operation is the most important prognostic factor.
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Affiliation(s)
- W M Fok
- Department of Orthopaedics and Traumatology, United Christian Hospital, Hong Kong.
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Doblar DD, Schumacher SD. Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor. Int J Obstet Anesth 2005; 14:256-60. [PMID: 15935638 DOI: 10.1016/j.ijoa.2004.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Revised: 08/01/2004] [Accepted: 09/01/2004] [Indexed: 11/29/2022]
Abstract
This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.
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Affiliation(s)
- D D Doblar
- Department of Anesthesiology, The University of Alabama, Birmingham, Alabama 35249-6810, USA.
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Chang FC, Lirng JF, Luo CB, Yen YS, Guo WY, Teng MMH, Chang CY. Evaluation of clinical and MR findings for the prognosis of spinal epidural haematomas. Clin Radiol 2005; 60:762-70. [PMID: 15978887 DOI: 10.1016/j.crad.2004.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 12/17/2004] [Accepted: 12/23/2004] [Indexed: 01/30/2023]
Abstract
AIM The potential of MR and clinical findings of spinal epidural haematomas (SEHs), particularly the early MR findings, to help minimize delays in diagnosis, to aid prognosis and as a reference for conservative treatment, are evaluated. METHODS Retrospectively 20 patients with SEHs (14 men and 6 women) were examined to record their neurological deficit, MR findings, management, clinical outcome, and interval between symptom onset and MRI or surgery. Two-tailed Fisher's exact test was used for these analyses. RESULTS Of 8 patients with severe neurological deficit at the onset of symptoms, none had obvious clinical improvement after either surgical or conservative management. Of 12 patients with mild to moderate deficits, 11 (92%) showed improvement or recovery of clinical symptoms. T2-weighted images revealed myelopathy or infarction of the compressed spinal cord in 9 patients, 7 (78%) of whom had no improvement in neurological deficit with either conservative or surgical management. Images in 6 patients showed contrast enhancement in the haematomas. CONCLUSION Poor clinical outcomes were observed mainly in those with severe neurological deficit and hyperintensity on T2-weighted images of the involved spinal cord. Surgery did not appear to improve outcome in many of these patients. In acute SEHs, MRI showed characteristic findings, such as contrast enhancement, which should not be confused with signs of inflammatory or neoplastic epidural disease.
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Affiliation(s)
- F-C Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
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Börm W, Mohr K, Hassepass U, Richter HP, Kast E. Spinal hematoma unrelated to previous surgery: analysis of 15 consecutive cases treated in a single institution within a 10-year period. Spine (Phila Pa 1976) 2004; 29:E555-61. [PMID: 15599276 DOI: 10.1097/01.brs.0000147743.46315.8b] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective clinical study. OBJECTIVES To determine characteristics, treatment methods, and outcome in an institutional series of patients with spinal hematoma not related to previous surgery. METHODS The charts of all patients with spinal hematoma treated in our institution between January 1993 and December 2002 were reviewed and analyzed with regard to location and extension of the hematoma, duration of symptoms, neurologic status, diagnostic measures, therapy, and outcome. RESULTS Fifteen patients were identified with spinal hematomas not caused by previous spine surgery. There were 11 women and 4 men. One hematoma was located subdurally and another intramedullary. All other hematomas were extradural, with 10 spontaneous bleedings. Eight hematomas were located in the cervical, two in the cervicothoracic, and three in the thoracic region. Two others were situated in the lumbar spine. Mean extension was 4.7 segments (range, 2-8 segments). Mean interval between onset of symptoms and surgery was 18 hours (range, 8-48 hours) for 12 patients; in 2 cases, diagnosis was made after 17 and 36 days, respectively, and then treated by surgery. One patient was treated without operation. Operative treatment was accomplished in all cases by hemilaminectomy and/or interlaminar fenestration and hematoma evacuation, in those cases with a larger extension of extradural hematoma by an alternating hemilaminectomy, thus reducing the risk of postoperative instability. There was no recurrence. No correlation between time to surgery and outcome was found in this study group, but there was a strong correlation between initial neurologic status and outcome after surgery. CONCLUSIONS Nonsurgical derived spinal hematomas are rare. In this series, most cases were spontaneous and located in the cervical or cervicothoracic region producing severe neurologic deficit and pain. Treatment should be surgical evacuation in the majority. As most hematomas are of great extension, alternating hemilaminectomy suffices for evacuation of extradural hematomas and supports the stability of the spinal segments. Outcome is highly dependent from initial neurologic status.
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Affiliation(s)
- Wolfgang Börm
- Neurosurgical Department, University of Ulm, Günzburg, Germany.
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Liao CC, Lee ST, Hsu WC, Chen LR, Lui TN, Lee SC. Experience in the surgical management of spontaneous spinal epidural hematoma. J Neurosurg 2004; 100:38-45. [PMID: 14748572 DOI: 10.3171/spi.2004.100.1.0038] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECT Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity. Although many cases have been reported in the literature, controversy persists as to its origin, diagnosis, and timing of treatment. The authors conducted a study in patients treated in their hospital and report the results. METHODS Clinical data obtained in 35 patients with SSEH were retrospectively reviewed. Age, sex, history of hypertension, and history of anticoagulation therapy were recorded, and data were analyzed to clarify the possible predisposing factors of SSEH. Neurological outcomes were reappraised using a standardized grading system and correlated with the time interval from initial ictus to surgery, duration of complete neurological deficits, and the rapidity of deterioration of paralysis. Nonparametric methods and Spearman rank-correlation coefficients were used for statistical analysis. CONCLUSIONS Surgery is a safe and effective procedure to treat SSEH. The disease-related mortality rate was 5.7%, the surgery-related complication rate was 2.9%, and there were no operation-related deaths. Neurological outcome after surgery is positively correlated with preoperative neurological deficits (88.9% complete recovery in patients with incomplete neurological deficits compared with 37.5% in those with complete deficits [p < 0.001]). In patients in whom the time interval from initial ictus was shorter (< 48 hours) and in whom the duration of complete neurological symptoms was also briefer (< 12 hours), there is a positive correlation with better neurological and functional recovery (p < 0.05).
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Affiliation(s)
- Cheng-Chih Liao
- Department of Neurosurgery, Chang Gung University, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Abstract
The authors report an acute epidural hematoma after the surgical removal of a cervical C6-C7 disc herniation through an anterolateral approach of the cervical spine. Clinical history consisted of respiratory distress and flaccid tetraplegia that appeared 2.5 hours after surgery. Without any complementary radiologic investigation, the patient was immediately transferred to the operating room for a second look, which was unsuccessful. Magnetic resonance imaging performed after this second surgical procedure showed an anterior cervical hematoma extending from C3 to T3 without significant spinal cord compression. A cervical laminectomy was performed to evacuate the hematoma. The patient was extubated the next morning and discharged from the hospital after 5 days with no residual neurologic deficit. An extensive postoperative investigation revealed no coagulation disorder.
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Affiliation(s)
- Pol Hans
- University Department of Anesthesia and Intensive Care Medicine, CHR de la Citadelle, Belgium.
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Rodríguez-Arias CA, Martínez R, Mac-Veigh I, Taboada M. [Epidural lumbar hematoma, epidural anesthesia and low-molecular-weight heparins]. Neurocirugia (Astur) 2001; 12:509-12. [PMID: 11787399 DOI: 10.1016/s1130-1473(01)70667-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Epidural hematoma is an uncommon but serious complication of epidural anaesthesia. The use of low molecular weight heparin (LMWH) as thromboprophylaxis has increased the occurrence of this pathology. We report the case of a 81-year-old man who underwent an arthroscopy of the knee, with epidural anaesthesia and administration of LMWH. The patient suffered an important pain due to a lumbar epidural haematoma which was diagnosed by magnetic resonance, after withdrawal of the epidural catheter. He improved after surgical evacuation, and no neurological deficit was present. We comment the association of LMWH, epidural anaesthesia and epidural haematoma.
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Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases. Spine (Phila Pa 1976) 2001; 26:E525-7. [PMID: 11707724 DOI: 10.1097/00007632-200111150-00025] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment. SUMMARY OF BACKGROUND DATA The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause. METHODS One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery. RESULTS Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified. CONCLUSIONS Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.
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Affiliation(s)
- S J Hentschel
- Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada
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Ghaly RF. Recovery after high-dose methylprednisolone and delayed evacuation: a case of spinal epidural hematoma. J Neurosurg Anesthesiol 2001; 13:323-8. [PMID: 11733665 DOI: 10.1097/00008506-200110000-00008] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Spinal epidural hematoma (SEH) is rare and not without serious sequelae. We report a patient who developed Brown-Séquard syndrome from SEH after fluoroscopic-guided cervical steroid injection and favorable response to methylprednisolone (MP). A 56-year-old man reported immediate sharp shooting pain to the upper extremities on introduction of epidural toughy needle. A total of 5 mL of 0.2% ropivacaine and 120 mg methylprednisolone acetate suspension was administered at the C6-7 interspace. Within half an hour, a neurologic deficit occurred at C7-8 and right Brown-Séquard syndrome developed. Once SEH was suspected (3 hours after onset of neurologic deficit), a protocol of high-dose MP intravenous infusion was initiated. Immediate incomplete recovery of motor, sensory, and sphincteric functions was noted within 30 minutes of infusion. Emergency spinal C6-T2 bilateral decompressive laminectomies and evacuation SEH were performed within an expected delay (10 hours from the onset of neurologic deficit). Fluoroscopic guidance does not take the place of adherence to meticulous technique. An unexplained neurologic deficit after invasive spinal procedures should raise the concern for SEH. Early recognition and emergent evacuation remain the mainstay management for SEH. This case suggests some neuroprotection from MP in cases of cervicothoracic cord compression secondary to traumatic SEH. When potential risks for SEH exist, it is advisable not to administer local anesthetic so as not to interfere with neurologic assessment and delaying the diagnosis.
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Affiliation(s)
- R F Ghaly
- Chicago Institute of Neurosurgery and Neuroresearch and Department of Anesthesiology and Pain Management, Cook County Hospital, Chicago, Illinois 60614, USA.
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Hui AC, Wong HT, Lam JM. Spinal epidural haematoma misdiagnosed as meningitis. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2001; 62:571. [PMID: 11584621 DOI: 10.12968/hosp.2001.62.9.1651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 32-year-old man developed sudden onset neck pain while at work. There was no headache, fever and no history of head or neck injury. He had been in good health. He continued to work and went home after seeing his doctor, who diagnosed muscle strain. Four days later the pain persisted and he was admitted to hospital. Examination revealed marked neck stiffness, generalized hyperreflexia but with preserved power and a fever of 38°C. Urgent computed tomography of the brain was normal. The blood white cell count was normal. CSF analysis revealed red blood cells and some white blood cells, a blood-stained high protein count of 7 g/litre and a low glucose of 0.7 mmol/litre. Simultaneous blood sugar concentration was 6.7 mmol/litre.
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Affiliation(s)
- A C Hui
- Department of Medicine, Prince of Wales Hospital, Shatin, Hong Kong
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Ferry P, Reisner C, Ashpole R. A case of spontaneous cervical extradural haematoma. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2001; 62:436-7. [PMID: 11480136 DOI: 10.12968/hosp.2001.62.7.1618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This 75-year-old woman was woken by sudden-onset left-sided neck and shoulder pain. As she walked a few steps, her legs gave way and she collapsed. Her feet felt 'dead', with the right side feeling worse, and she felt pins and needles over both upper limbs. She had no headache, loss of consciousness, chest pain or palpitations. She had a past history of large joint osteoarthritis, cervical radiculopathy and essential hypertension. Two months previously, she had fallen to the ground while standing on a chair and had, in the process, hit the back of her head. She had suffered no immediate ill effects from this. She was on doxazosin, lisinopril and diclofenac. She lived alone and was normally fully mobile and independent.
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Affiliation(s)
- P Ferry
- Queen's Hospital, Burton Upon Trent DE13 ORB
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La Rosa G, d'Avella D, Conti A, Cardali S, La Torre D, Cacciola F, Longo M, Tomasello F. Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases. J Neurosurg 1999; 91:128-32. [PMID: 10419360 DOI: 10.3171/spi.1999.91.1.0128] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.
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Affiliation(s)
- G La Rosa
- Department of Neurosurgery, University of Messina School of Medicine, Italy
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