Traumatic epidural hematoma of the cervical spine: magnetic resonance imaging diagnosis and spontaneous resolution: case report

Epidural hematoma treated by aspiration after transforaminal epidural steroid injection - A case report

Background

Spinal epidural hematoma is rare condition that can rapidly develop into severe neurologic deficits. The pathophysiology of this development remains unclear. There are several case reports of emergency hematoma evacuations after epidural steroid injection.

Case

We report on two patients who developed acute, large amounts of epidural hematoma without neurological deficits after transforaminal epidural steroid injection. After fluoroscopy guided aspiration for epidural hematoma was performed, neurological defects did not progress and the hematoma was shown to be absorbed on magnetic resonance imaging.

Conclusions

These reports are believed to be the first of treating epidural hematoma occurring after transforaminal epidural steroid injection through non-surgical hematoma aspiration. If large amounts of epidural hematoma are not causing neurological issues, it can be aspirated until it is absorbed.

Post-traumatic cervical spine epidural hematoma: Incidence and risk factors

BACKGROUND

The incidence and risk factors for post-traumatic cervical epidural hematoma are not well described in the current literature. Our aim was to determine the incidence and associated risk factors for post-traumatic cervical spine epidural hematoma (SEH).

METHODS

We performed a retrospective review of our institution's prospectively collected data submitted to the state trauma registry, using ICD-9 codes, for all patients activated as a trauma with cervical spine injuries, between the years 2010 and 2014. Patients with MRI available were classified based on the presence of cervical epidural hematoma (CEH) or no hematoma (NEH). For our second analysis, we classified patients with cord compression associated with an epidural hematoma (CC) and no cord compression (NCC). Potential risk factors evaluated included: INR, PTT, albumin and platelets levels, radiographic findings of Ankylosing Spondylitis (AS), and ISS. No conflicts of interest exist and/or funding was used for this study.

RESULTS

497 out of 1810 trauma activations met our inclusion criteria. 46 patients (2.5%) were found to have a post-traumatic cervical SEH (CEH). Of the CEH cohort, 76% were male, with 72% Caucasian, and a mean age of 55 years. 27 patients (5.4%) were found to have cervical cord compression at the level of the SEH. Of the CC arm, 78% were male, with 67% Caucasian, and a mean age of 56 years. A higher ISS and an elevated INR were found to be associated with epidural hematoma causing cord compression.

CONCLUSIONS

An incidence of 2.5% is reported for post-traumatic cervical spine epidural hematoma. Of these, 59% had associated spinal cord compression. Patients with a higher ISS and elevated INR levels are at a higher risk for developing this potentially devastating.

Two cases of spontaneous cervical epidural hematoma without back or neck pain in elderly Japanese men

Cases

Spontaneous spinal epidural hematoma (SSEH) is an uncommon disease. Most SSEH cases involve back and/or neck pain. We report the cases of two men who experienced SSEH with dysstasia but without back or neck pain.

Outcomes

This study presents two cases involving elderly Japanese men who visited an emergency department because of sudden dysstasia without back or neck pain. The results of the neurological examinations revealed ataxic gait. Cervical spinal epidural hematomas were observed by computed tomography and magnetic resonance imaging. One patient underwent hematoma removal and decompression by corpectomy, whereas the other patient received conservative treatment and observation. The patients were discharged without sequelae.

Conclusion

Spinal epidural hematomas are difficult to diagnose, and a delayed diagnosis can adversely affect the patient's quality of life. These hematomas should be considered in the differential diagnosis of cerebrovascular diseases.

Imaging characteristics of cervical spine extra-arachnoid fluid collections managed conservatively

OBJECTIVE

Determine the MRI characteristics of large post-traumatic cervical spine extra-arachnoid collections managed conservatively in clinically stable patients and whether evidence of clinical or imaging deterioration materialized.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective search for all patients (>16 years old) over a 17-months period who had an extra-arachnoid fluid collection reported on a post-traumatic cervical spine MRI. Patients were excluded if they had surgery for an unstable fracture (n = 21), emergent decompression (n = 1) or lacked a follow-up MRI within 15 days (n = 1). Two MSK radiologists recorded the size, morphology and MRI signal characteristics of the collections.

RESULTS

Eight patients (5 male, 3 female) met the inclusion criteria (mean age 40 years; range 19-78 years). Seven of the eight patients had fluid collections that demonstrated thin, tapered margins, extended >7 vertebral bodies and involved >180 degrees of the spinal canal. The signal characteristics of these collections varied: hyper-T1/iso-T2 (n = 1), iso-T1/T2 (n = 3), hyper-T1/hypo-T2 (n = 3) and mixed-T1/T2 (n = 1). Six of seven collections were ventral. Follow-up MRI demonstrated resolution/significant decrease in size (n = 4 between 1 and 12 days) or no change/slight decrease in size (n = 3; between 2 and 11 days). None of the seven fluid collections enlarged, no patient had abnormal cord signal, and no patient's neurologic symptoms worsened. One of eight patients had a dorsal "mass-like" collection that was slightly smaller 9 days later.

CONCLUSION

In stable patients with large, tapered post-traumatic cervical spine extra-arachnoid collections managed non-surgically, none developed (1) clinical worsening, (2) abnormal cord signal or (3) collection enlargement, regardless of the collection's signal characteristics.

Acute Cervical Spontaneous Spinal Epidural Hematoma Presenting with Minimal Neurological Deficits: A Case Report

Introduction

Spontaneous spinal epidural hematoma (SSEH) is an uncommon but potentially fatal condition. The increased bleeding tendency associated with anticoagulant medications has been proven to increase the risk of SSEH. The symptoms of SSEH usually begin with sudden severe neck or back pain and are followed by neurological deficits. However, some cases present with only axial pain or with radicular pain similar to herniated disc disorders.

Case Presentation

A 28-year-old healthy man developed a sudden onset of severe neck and right shoulder pain with mild arm weakness. The MRI revealed an SSEH that was compressing his spinal cord in the right posterolateral epidural space from C2-C6. On the second hospital day, his symptoms suddenly improved, and most of the hematoma had spontaneously resolved.

Conclusions

Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present.

Idiopathic Thoracic Spontaneous Spinal Epidural Hematoma

A 33-year-old male patient experienced temporary sensory loss and weakness in the right lower extremity one month prior to admission. The patient was admitted to a private clinic with a three-day history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the Guillain-Barre syndrome (GBS). The patient was subsequently transferred to our clinic and the neurologic examination revealed paraplegia in both lower extremities, positive bilateral Babinski signs, and hypesthesia below the T10 dermatome with saddle anesthesia. The patient had urinary incontinence and thoracic magnetic resonance imaging (MRI) showed an image of a mass compressing the medulla.

[Spontaneous spinal epidural hematoma as cause of incomplete spinal cord injury]

Spontaneous spinal epidural hematomas are rare but are of differential diagnostic importance due to the potentially dramatic progression through to irreversible neurological deficits. At the beginning the clinical symptoms are non-specific and the development of neurological deficits leads to the diagnosis. We present the case of a 73-year-old female patient who initially reported uncharacteristic neck pain and developed incomplete quadriplegia during the next day as well as the case of a 78-year-old male patient, who complained of acute back pain and developed paraplegia a short time afterwards. Early microsurgery and spinal canal evacuation led to complete remission of the neurological deficits in both cases.

Delayed neurological deficits induced by an epidural hematoma associated with a thoracic osteoporotic compression fracture

A 79-year-old woman developed neurological deficits 6 weeks after the onset of a thoracic osteoporotic compression fracture. Magnetic resonance (MR) imaging of the thoracic spine revealed an epidural hematoma at the T10-L2 levels. Acute decompressive laminectomy and percutaneous vertebroplasty were performed. Following the surgery, the patient's neurologic deficits improved and follow-up MR imaging showed complete resolution of the hematoma. Spinal epidural hematomas are rare and associated delayed neurological deficits are extremely rare. Conservative treatment may be effective for epidural hematomas in neurologically intact patients, but epidural hematomas can be a cause of neural compression and symptomatic deterioration resulting in delayed neurological deficits during the follow-up period.

Delayed traumatic spinal epidural hematoma with neurological deficits

To describe the mechanism that causes spinal epidural hematoma with neurologic deficit and review the literature. We report a case of a 62-year-old man with post-traumatic epidural hematoma in the cervicothoracic spine, who developed progressive neurological deficit which eventually resulted in complete paralysis below T1. During surgical evacuation significant spine compression due to an organizing hematoma was observed. After surgery, the patient's motor function improved and there was a complete recovery of the neurologic deficit after a rehabilitation program.

CONCLUSION

Epidural hematoma can happen after delayed traumatic event leading to a variable degree of neurologic damage.

Spontaneous resolution of a traumatic cervicothoracic epidural hematoma presenting with transient paraplegia: a case report

STUDY DESIGN

Case description.

OBJECTIVE

To clinically and radiographically describe a traumatic spinal epidural hematoma (TSEH) without adjacent spinal column fracture or soft tissue injury that completely resolved, without surgical intervention.

SUMMARY OF BACKGROUND DATA

Symptomatic TSEH is an infrequent condition after spinal trauma, accounting for 0.5% to 1.7% of cases. It can result in permanent neurologic deficits if not treated in a timely and appropriate manner.

METHODS

A 50-year-old man presented with progressive lower motor weakness and sensory change at 2 days after blunt trauma to the upper back area. Neurologic examination revealed paraplegia and hypesthesia below the T4 sensory dermatome. Magnetic resonance imaging for cervicothoracic spine showed a space-occupying lesion in the dorsal spinal epidural space from C7 to T5. The lesion was consistent with acute stage hematoma of the spinal epidural space.

RESULTS

The patient was prepared for decompression surgery. However, the patient's neurologic symptoms began to improve (grade 4/5) at 2 hours after onset of paraplegia. Surgical intervention was delayed, and the patient was treated conservatively with close neurologic monitoring. Three days after onset of symptoms, the patient's neurologic symptoms recovered completely. The follow-up magnetic resonance imaging at 12 days after the event showed complete resolution of the epidural hematoma.

CONCLUSION

An unpredictable extensive epidural hematoma can occur after blunt trauma of the cervicothoracic spine in patients at low risk for hemorrhage. This case illustrates that immediate surgical intervention may not always be necessary in certain patients with TSEH. Conservative management with careful observation may play a role as a management option for patients initially presenting with severe neurologic dysfunction if neurologic recovery is early and sustained.

Delayed Onset Neurological Deterioration due to a Spinal Epidural Hematoma after a Spine Fracture

There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.

Delayed traumatic thoracic spinal epidural hematoma: a case report and literature review

Spinal epidural hematoma is a relatively uncommon disease, but an important cause leading to cord compression. Posttraumatic spinal epidural hematoma is a rare entity and remains a challenge for clinical physicians. Magnetic resonance imaging is the best choice for early diagnosis, and urgent surgical decompression with evacuation of hematoma could improve some neurologic deficits, especially vital cord functions. We presented a 77-year-old woman who sustained back pain after a fall 1 month before admission, complaining of progressive weakness and sensory loss in bilateral lower extremities since 2 weeks before admission. Radiography of the thoracic spine revealed decreased body height at T10 and compression fracture. Magnetic resonance imaging of the thoracic spine revealed epidural hematomas at the level of T11 to T12. An urgent decompressive laminectomy with evacuation of hematoma was performed immediately. Postoperatively, her previous neurologic deficits improved except for an underactive neurogenic bladder and fecal incontinence.

Spinal cord compression from traumatic anterior cervical pseudomeningoceles

✓Pseudomeningoceles rarely develop after cervical trauma; in all reported cases the lesions have extended outside the spinal canal.

The authors report the first known cases of anterior cervical pseudomeningoceles contained entirely within the spinal canal and causing cord compression and neurological injury. The authors retrospectively reviewed the cases of three patients with traumatic cervical spine injuries and concomitant compressive anterior pseudomeningoceles. The lesion was recognized in the first case when the patient’s neurological status declined after he sustained a severe atlantoaxial injury; the pseudomeningocele was identified intraoperatively and decompressed. After the decompressive surgery, the patient’s severe tetraparesis partially resolved. In the other two patients diagnoses of similar pseudomeningoceles were established by magnetic resonance imaging. Both patients were treated conservatively, and their mild to moderate hemiparesis due to the pseudomeningocele-induced compression abated.

The high incidence of anterior cervical pseudomeningoceles seen at the authors’ institution within a relatively brief period suggests that this lesion is not rare. The authors believe that it is important to recognize the compressive nature of these lesions and their potential to cause devastating neurological injury.

Epidural hematoma after immobilization of a "hangman's" fracture: case report and review of the literature

BACKGROUND CONTEXT

Neurologic deterioration after immobilization of traumatic spondylolisthesis of the axis rarely occurs because of the decompressive nature of the injury itself and the large amount of space available for the cord in the upper cervical spine.

PURPOSE

To document neurologic deterioration after reduction (without the use of traction) and halo immobilization of a Type IIA traumatic spondylolisthesis of the axis (hangman's fracture) secondary to an epidural hematoma.

STUDY DESIGN/SETTING

Case report. PATIENT SAMPLE AND OUTCOME MEASURES: The patient population consisted of one patient; no outcome measures were used.

METHODS

The medical record and radiographic studies of a 27-year-old patient involved in a motor vehicle crash that resulted in a traumatic spondylolisthesis of the axis were retrospectively reviewed, and a review of the English literature was performed.

RESULTS

Upon evaluation, the patient was found to have, in addition to other injuries, a Type IIA hangman's fracture of the C2 vertebra, which was stabilized in a halo. Shortly thereafter, the patient developed a gradual progressive neurologic deficit. Magnetic resonance imaging revealed the presence of a large epidural hematoma with cord compression treated with posterior laminectomy and transdural decompression of an anterior hematoma. Postoperatively, the patient's neurologic examination improved and returned to normal within 6 months.

CONCLUSION

An epidural hematoma can occur after traumatic spondylolisthesis of the axis, but its symptoms may not present until after the spondylolisthesis is treated.

Spontaneous spinal epidural hematoma: A case report

A 59-year-old man presented to the emergency department (ED) the day after a minor motor vehicle crash for evaluation of bilateral shoulder pain. He underwent ED evaluation for his back pain two more times before it was found that he had a spontaneous spinal epidural hematoma (SSEH). On the third visit, the patient had waxing and waning neurologic symptoms including lower extremity weakness and urinary retention. The diagnosis was made by MRI, and the patient was successfully treated with cervical hemilaminectomy at the cervicothoracic junction for evacuation of the epidural hematoma 5 days after the onset of back pain.

Spontaneous spinal epidural haematoma: report of two cases and review of the literature

The clinical presentation, investigation, management and outcome of two patients with spontaneous spinal epidural haematoma (SSEH) are presented. CT myelogram revealed an extradural compressive lesion in one patient and MRI confirmed extradural haemorrhage in the second. Both the cases were treated surgically. One patient made a complete recovery and the other made no neurological recovery. The clinical presentation, diagnosis, treatment and factors determining the outcome of SSEH are discussed and the literature reviewed.

Acute traumatic spinal epidural hematoma: imaging and neurologic outcome

The purpose of this study was to present MRI characteristics of traumatic spinal epidural hematomas (TSEHs) and to evaluate their effect on neurologic outcome. A retrospective analysis was performed of all 74 cases in which patients underwent emergent spinal MRI in the setting of acute trauma at our institution's Emergency Department between June 2002 and January 2003. MRI studies were evaluated for the presence of a TSEH. CT studies were evaluated for the presence of osseous trauma. Patient data were collected from medical records on the initial neurologic status at admission and at 6 months after injury. Twenty-seven of 74 patients had a spinal fracture and a TSEH. Twenty-five of 74 patients had a spinal fracture with no TSEH. Twenty-two of 74 patients had normal imaging studies. Six-month follow-up of neurologic status demonstrated no statistically significant difference in neurologic outcome between patients with spinal fractures and TSEH and those with spinal fractures but no TSEH. If a spinal fracture and abnormal neurologic exam are present, the neurologic outcome at 6 months is not worsened by the presence of a TSEH.

Delayed traumatic spinal epidural hematoma with spontaneous resolution of symptoms

Post-traumatic spinal epidural hematomas are uncommon, usually requiring emergent neurosurgical evacuation. We present a symptomatic delayed post-traumatic epidural hematoma of the T-spine that resolved within hours of administration of high dose steroids. A 22-year-old man presented 10 days after sustaining blunt trauma during a motor vehicle crash. He developed signs of acute cord compression with loss of sensation and motor function in bilateral lower extremities with priapism. Magnetic resonance imaging demonstrated a spinal epidural hematoma with 50% canal stenosis at the T4 level. His symptoms improved 1 h after the administration of high dose steroids. All symptoms resolved completely while the patient was in the Emergency Department and he was treated conservatively by Neurosurgery with no further sequelae. Thoracic spinal epidural hematoma is an uncommon condition that may present in delayed fashion after trauma with significant neurologic compromise. If neurologic symptoms improve with initial steroid therapy, patients with this condition may be treated conservatively with steroids and observation.

Cervical epidural haematoma with clivus fracture: case report

Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.

Acute cervical epidural hematoma: case report

A 74 year-old patient with a nocturnal onset of neck and chest pain was brought to an emergency clinic. Physical examination and cardiac assessment were normal. Three hours after the addmittance, a flaccid paralysis of the four limbs supervened. Suspecting of an unusual onset of central nervous system infection, a lumbar puncture was performed, yielding 20 ml of normal cerebrospinal fluid. Thirty oinutes after the puncture, the patient completely regained neurological funcion. He was then referred to a General Hospital where a computed tomography (CT) scan was done showing a large cervical epidural bleeding in the posterolateral region of C4/C5 extending to C7/Th1, along with a C6 vertebral body hemangioma. A magnetic resonance imaging revealed the same CT findings. A normal selective angiography of vertebral arteries, carotid arteries and thyreocervical trunk was carried out. Spontaneous spinal epidural hematoma (ASSEH) is a rare but dramatic cause of neurological impairment. In this article we report a fortunate case of complete recovery after an unusual spine cord decompression. We also review the current literature concerning diagnosis and treatment of ASSEH.

Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases

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.