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Kahraman MA, Senturk S. The Necessity of Extensive Decompression for Spinal Epidural Hematoma: A Case Report and Literature Review. Cureus 2023; 15:e44192. [PMID: 37641725 PMCID: PMC10460501 DOI: 10.7759/cureus.44192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 08/31/2023] Open
Abstract
Spinal epidural hematomas (SEHs)are space-occupying lesions that exert pressure on the spinal cord by rapidly accumulating blood between the dura and bone or ligament components. The annual incidence of spontaneous epidural hematoma is estimated to be one in one million. The predominant symptoms are back pain or neurological impairment, including sensory, motor, or autonomic dysfunction of the limbs below the hematoma level. Depending on the level and size of the hematoma and the affected cord, they cause neurological deficits. Neurological deficits are often reversible if diagnosed and treated early with surgical decompression. However, neurological deficits can become permanent if the patient is not operated on timely, and paraplegia or quadriplegia may occur. A 53-year-old man presented to our emergency department with acute-onset back pain and 36-hour-long, rapidly progressive paraparesis of both legs. On T1- and T2-weighted MRI scans, a hyperacute SEH was found as iso/hyperintense and hyperintense, respectively. Immediate decompressive laminectomy from T10 to L2 and hematoma evacuation were performed. It was challenging to remove the hematoma due to its firm consistency. Before performing a bilateral total laminectomy at five levels, the posterior spine was stabilized between T10 and L3 using transpedicular screws. Within 24 hours, the motor function of the lower limbs increased considerably. The patient could sit on a chair because of posterior stability. In addition to the importance of early diagnosis using imaging techniques, planning the extension of SEH surgery is crucial for the patient's postoperative neurological recovery.
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Affiliation(s)
- Mehmet Ali Kahraman
- Neurosurgery, Istanbul Medeniyet University, Prof. Dr. Suleyman Yalcin City Hospital, Istanbul, TUR
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Okazaki T, Nakagawa H, Hayase H, Irie S, Inagaki T, Saito O, Yamashina M, Nagahiro S, Saito K. Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures. Neurol Med Chir (Tokyo) 2018; 58:138-144. [PMID: 29415912 PMCID: PMC5929923 DOI: 10.2176/nmc.cr.2017-0052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Spontaneous and chronic epidural hematoma (SSEH) in the lumbar spine is rare, and idiopathic and chronic SSEH in the lumbar spine is extremely rare disease. Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. Definitive guidelines for management of this condition are not clear and surgical total evacuation was performed in most of the cases. Some authors reported the epidural bleeding originates in the rupture of Batson’s plexus due to a rise in intra-abdominal pressure, but the mechanism is not clearly clarified. We report a surgical case of idiopathic and chronic SSEH. A 61-year-old woman suffered a sudden onset of severe lumbar pain during sleep. She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5. This patient underwent the partial evacuation of the hematoma with partial hemilaminectomy on left at L2/3, resulting in immediate pain relief and resolution of symptoms and almost absorption of the hematoma within 1 week of the procedure. We presented this rare case and reviewed idiopathic and chronic epidural hematoma in the lumbar spine.
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Affiliation(s)
- Toshiyuki Okazaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital.,Department of Neurosurgery, Tokushima University
| | | | - Hitoshi Hayase
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Shinsuke Irie
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Toru Inagaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Osamu Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | | | | | - Koji Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
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Shivapathasundram G, Sammons V, Bazina R. Metastatic thymoma presenting as spontaneous epidural lumbar haematoma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25 Suppl 1:33-7. [DOI: 10.1007/s00586-015-4043-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
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Abstract
ABSTRACT:Background:Spontaneous spinal epidural hematoma is a rare phenomenon that has no distinct etiology. Spontaneous spinal epidural hematoma (SSEH) during pregnancy is extremely rare. We present what we believe to be the fifth reported case of spontaneous spinal epidural hematoma associated with pregnancy in the English literature.Methods:A 31-year-old female presented with acute onset of paraplegia at 32 weeks of pregnancy. The patient had a T2 sensory level and complete paralysis of all lower extremity motor groups. Magnetic resonance imaging of the thoracic spine showed an acute epidural hematoma posterior to the thoracic spinal cord between the second and fourth thoracic vertebrae.Results:The patient was taken to the operating room were her child was delivered by caesarean section. She then underwent a posterior laminectomy and evacuation of a spinal epidural hematoma. Followup selective spinal angiography was negative for any vascular malformation. The patient gradually recovered lower extremity function and was independently ambulating at six month follow-up. Voluntary bowel and bladder function returned within four months but twice daily intermittent catheterization remained necessary for excessive post-void residual urine.Conclusions:Spontaneous spinal epidural hematoma in pregnancy is a rare phenomenon. It is postulated that elevated venous pressure associated with pregnancy may be a contributing factor. In the reported cases of SSEH in pregnancy most patients presented with acute symptoms, thoracic location and profound neurological deficits but, with prompt surgical treatment, generally had good long term recovery.
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Affiliation(s)
- Michael E B Kelly
- Division of Neurology, Royal University Hospital, University of Saskatchewan, Saskatoon, SK, Canada
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Borkar SA, Prasad GL, Satyarthee GD, Mahapatra AK. Spontaneous spinal extradural hematoma in a child with hemophilia B, surgery or medical management - A dilemma? J Pediatr Neurosci 2012; 6:131-3. [PMID: 22408664 PMCID: PMC3296409 DOI: 10.4103/1817-1745.92837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Spontaneous spinal extradural hematoma is a rare clinical scenario which may be secondary to a variety of etiologies. Spinal epidural hematoma is an extremely rare complication in hemophiliacs. It usually runs an acute course often leading to rapid onset of neurological deficits. MR imaging is the diagnostic modality of choice and early, prompt treatment will often yield fruitful results. We report a case of spontaneous spinal EDH in a 5-year-old male child with Hemophilia B, who was managed conservatively and was doing well at last follow-up, 2 years after treatment. The authors discuss the role of factor replacement therapy vis-a-vis surgery in such a scenario.
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Affiliation(s)
- Sachin A Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Wu YT, Chiang SL, Lai MH, Lu SC, Chang CC, Chang ST. Methylprednisolone worsening neuropathic pain in non-traumatic thoracic myelopathy. J Clin Pharm Ther 2010; 35:491-6. [PMID: 20831552 DOI: 10.1111/j.1365-2710.2009.01121.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Methylprednisolone (MP) is the only neuroprotective medication currently in widespread use for the treatment of spinal cord injury. Increasingly, published studies challenge its clinical effects in view of its serious side-effects including wound infection, pneumonia, sepsis and steroid myopathy. Most cases with spontaneous spinal epidural haematoma (SSEH) need emergency evacuation, and typically show good neurologic recovery. Some patients with SSEH given preoperative or postoperative MP within hours of the onset of symptoms, and have had good motor recovery, although no mention was made of sensory function. Severe, intractable neuropathic pain has not been reported in patients with SSEH. We present a case of SSEH treated with a high-dose MP 16 h after onset of symptoms. Surgical decompression was performed 1 h after MP treatment. Motor recovery was good; however, intractable neuropathic pain developed 5 weeks postoperatively. We discuss the factors contributing to intractable pain. We speculate that the severe, intractable pain might be due to misuse of large-dose steroids in this case of non-traumatic spinal myelopathy, and not because of the injury per se.
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Affiliation(s)
- Y-T Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Neihu District, Taipei, Taiwan
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Abstract
STUDY DESIGN Case report. OBJECTIVE To describe 2 patients of spinal osteoblastoma in upper thoracic lamina, complicated with epidural hematoma and symptoms of cord compression. SUMMARY OF BACKGROUND DATA Review the clinical presentation, radiologic findings, and treatment in these 2 cases, with an emphasis on surgical management and outcomes. METHODS Two patients initially presented with symptoms of incomplete neurological deficit after mild injury. Computer tomography scan indicated osteolytic destruction of thoracic lamina; magnetic resonance imaging illustrated that lesion in the posterior element of thoracic spine with epidural hematoma and sign of spinal cord compression. Marginal surgical resection and hematoma evacuation were performed. RESULTS Histologic diagnosis indicated destructive osteoblastomas with hemorrhage. Complete neurologic recovery was achieved at 1 week and 3 months after surgery. Both patients had no evidence of tumor recurrence at an average follow-up of 37 months. CONCLUSION By using surgical resection and hematoma evacuation, good outcome could be achieved for spinal osteoblastoma complicated with epidural hematoma.
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Abstract
STUDY DESIGN Case report. OBJECTIVE To report a long segment epidural hematoma with thoracic cord compression caused by a metastatic carcinoma. SUMMARY OF BACKGROUND DATA To our knowledge, there have been no previous reports of spontaneous spinal epidural hematoma caused by metastatic carcinoma. METHODS A 60-year-old woman with back pain and progressive leg weakness suddenly developed complete paraplegia and anesthesia below T8. A thoracic spine MRI showed an epidural hematoma and metastatic tumor. We describe the clinical course, radiographic imaging, operative findings, and treatment results. RESULTS Despite immediate surgery, the patient failed to have any significant improvement in her neurologic symptoms. A previously unsuspected primary lung tumor was diagnosed. She died 6 months after spine surgery. CONCLUSION Spinal epidural hematoma can occur in association with metastatic tumors in that area.
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Nojiri H, Kim S, Tsuji T, Uta S. Spontaneous spinal epidural hematoma as the initial presentation of leukemia. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18 Suppl 2:220-3. [PMID: 19127372 DOI: 10.1007/s00586-008-0863-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 12/02/2008] [Accepted: 12/14/2008] [Indexed: 01/30/2023]
Abstract
We present a case of a 55-year-old male with progressive neurological deficits that appeared dramatically. MRI detected a spinal epidural hematoma at the cervicothoracic junction and blood tests showed leukocytosis, mild anemia, and thrombocytosis. Spontaneous spinal epidural hematoma (SSEH) as the initial presentation of leukemia was diagnosed. Urgent posterior decompression was performed after 28 h from acute onset of backache, and the patient experienced remarkable improvement in neurological findings.
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Affiliation(s)
- Hidetoshi Nojiri
- Department of Orthopaedics, Saisei Hospital, 800-1 Kashiwai-cho, Hanamigawa-ku, Chiba, Japan.
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Padosch SA, Dettmeyer RB, Schmidt PH, Musshoff F, Madea B. Spinal epidural haematoma after blunt trauma to the neck and hyperflection of the cervical spine. Forensic Sci Int 2006; 159:230-4. [PMID: 16289414 DOI: 10.1016/j.forsciint.2005.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Revised: 05/23/2005] [Accepted: 09/28/2005] [Indexed: 11/29/2022]
Abstract
Spinal epidural haematomas (sEDH) can be regarded as rare events, in principle a spontaneous and a traumatic aetiology can be distinguished. Spontaneous spinal epidural haematomas can arise, e.g. from vascular malformations, coagulopathies, etc. On the other hand, traumatic sEDH are related to, e.g. spinal trauma or intraoperative vascular injuries. With regard to clinical significance, spinal epidural haematomas accompanied by transient mild neurological symptoms up to lethal outcomes have been observed. We report on a 53-year-old male alcoholic who was found in the kitchen of his asylum in a grotesquely fixed body position, with his head and cervical spine in a maximum anteflected position. A general practitioner had ruled for a non-natural manner of death due to "broken neck" and alcohol intoxication, therefore, the prosecution authorities called for a medicolegal autopsy. At autopsy, paravertebral soft tissue haemorrhage in between the shoulder blades was disclosed. Furthermore, a spinal epidural haematoma, extending from the foramen magnum down to the middle portion of the thoracic spine was found. No fractures of vertebrae nor lesions of spine ligaments or bleedings of intervertebral discs were found. Blood alcohol concentration was determined 1.92 g/l and urine alcohol concentration was 1.76 g/l. Further morphological findings were cerebral oedema and cardiac hypertrophy; the urinary bladder was found filled to bursting. Neuropathological investigations confirmed the presence of the spinal epidural haematoma and assigned lethal significance to this finding. There were no histological signs of axonal injury. Reconstruction revealed that when sitting on a chair in a drunk condition, the individual's upper part of the body had fallen backwards in the corner and subsequently got stuck with maximum anteflection of the head and cervical spine, causing rupture of vessels and spinal epidural haematoma. Acute respiratory failure caused by impairment of the phrenic nerve following spinal epidural haematoma with potential synergism of alcohol intoxication was ascertained as the cause of death.
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MESH Headings
- Alcoholic Intoxication/complications
- Alcoholic Intoxication/diagnosis
- Alcoholic Intoxication/pathology
- Autopsy
- Cervical Vertebrae/injuries
- Diagnosis, Differential
- Forensic Pathology
- Hematoma, Epidural, Spinal/complications
- Hematoma, Epidural, Spinal/diagnosis
- Hematoma, Epidural, Spinal/pathology
- Humans
- Male
- Middle Aged
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/pathology
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Affiliation(s)
- S A Padosch
- Department of Legal Medicine, University of Bonn, Stiftsplatz 12, D-53111 Bonn, Germany.
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Ravi D, Dwarakanath S, Satish R, Gopal S, Venkataramana NK. Spontaneous spinal extradural hematomas. J Clin Neurosci 2006; 13:269-72. [PMID: 16503490 DOI: 10.1016/j.jocn.2005.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Accepted: 03/22/2005] [Indexed: 11/20/2022]
Abstract
We review three patients who presented with acute spontaneous spinal extradural hematomas (SSEH). We discuss the presentation, imaging and management strategies. All three patients were adult women with thoracic SSEH. All had motor weakness prior to surgery. One patient recovered completely, one partially recovered and one did not recover. SSEH, although rare, should be considered in cases of acute onset paraparesis. The diagnostic modality of choice is magnetic resonance imaging. Favourable outcome is related to aetiology, interval between the ictus and presentation, and the severity of the neurological deficits. Emergent surgical drainage is the treatment of choice.
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Affiliation(s)
- D Ravi
- Department of Neurosurgery, Manipal Institute for Neurological Disorders, (MIND), Airport Road, Bangalore 560 017, India
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Tashjian RZ, Bradley MP, Lucas PR. Spinal epidural hematoma after a pathologic compression fracture: an unusual presentation of multiple myeloma. Spine J 2005; 5:454-6. [PMID: 15996616 DOI: 10.1016/j.spinee.2005.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2004] [Accepted: 03/05/2005] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural hematoma can result from traumatic and atraumatic etiologies. Atraumatic spinal epidural hematomas have been reported as an initial presentation of multiple myeloma. There are no other reports previously describing spinal epidural hematoma after a pathologic spinal fracture. PURPOSE To present the first reported case of a spinal epidural hematoma after a pathologic fracture and a very unusual initial presentation of multiple myeloma in a young patient. STUDY DESIGN/SETTING Case report. METHODS A healthy asymptomatic 37-year-old male was struck in the head with a ball while playing soccer. Initial symptoms included severe back pain without neurologic symptoms. Complete motor paralysis developed over the next 24 hours in the lower extremities with a sensory level of T10. Magnetic resonance imaging evaluation of the spine revealed a T6 compression fracture with a dorsal T3 to T10 epidural hematoma. The patient underwent surgical T2 to T8 posterior spinal decompression with evacuation of the hematoma. Serum and urine electrophoresis and bone marrow biopsy were performed. RESULTS The results of the electrophoresis revealed an immunoglobulin A monoclonal spike. The bone marrow biopsy was positive for plasma cell myeloma. Recovery of some motor function was noted in both lower extremities postoperatively. The patient was subsequently started on steroids and chemotherapy for myeloma. The patient has also undergone bone marrow transplant, and his myeloma is currently in remission. CONCLUSION This is the first reported case of spinal epidural hematoma after a pathologic spinal fracture. Also, this case represents an unusual initial presentation of multiple myeloma in a young patient.
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Affiliation(s)
- Robert Z Tashjian
- Brown Medical School, Rhode Island Hospital, Department of Orthopaedic Surgery, 2 Dudley Street, Providence, RI 02905, USA.
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Abstract
We present two patients who had acute paraplegia with sensory loss due to spontaneous spinal epidural hematoma (SSEH). One had myocardial infraction and the other had deep vein thrombosis, and the former was treated with anticoagulants and the latter was treated with thrombolytic agent. We analyzed the neurological status of our two cases each between its preoperative and postoperative state. Postoperatively both showed no improvement of neurologic symptom, and on follow-up of 12 months, one showed no neurologic improvement and the other showed a insignificant improvement of lower extremity muscle power (trace knee extensor/ankle dorsi-flexor). We thought that this poor outcome was due to delayed operation, which was done more than 24 hr after the symptom onset. The outcome in SSEH is essentially determined by the time taken from symptom onset to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is necessary.
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Affiliation(s)
- Kyung-Jin Song
- Department of Orthopaedic Surgery, College of Medicine, Institute for Medical Science, Chonbuk National University Medical School, Chonju, Korea
| | - Kwang-Bok Lee
- Department of Orthopaedic Surgery, College of Medicine, Institute for Medical Science, Chonbuk National University Medical School, Chonju, Korea
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Affiliation(s)
- Rahul Banerjee
- Department of Orthopedics, Brown University School of Medicine, Providence, RI, USA
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