Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases

Spontaneous epidural and subdural hematomas of the spine: Review of anatomy and imaging findings

Spontaneous epidural (SEH) and subdural hematomas (SSH) of the spine are a rare cause of spinal injury and morbidity. They often present in the emergency setting, though magnetic resonance imaging is the gold-standard for diagnosis. Knowledge of anatomy, and in particular of the dural layers of the spine, is crucial to understand the location of SEH and SSH and their relationship with spinal structure. In this pictorial review, we aim to explain imaging features of the SEH and SSH, and to rule out their main differential diagnosis.

Prognosis and outcome of chronic pain after spontaneous spinal epidural hematoma

OBJECTIVE

Chronic pain is a common symptom experienced by patients after spontaneous epidural hematoma (SSEH), and it seriously affects their quality of life. The outcome and prognosis of chronic pain after SSEH are rarely reported. Thus, we conduct this study to present the outcomes and explore prognostic factors of chronic pain in patients with SSEH.

METHODS

We retrospectively reviewed patients diagnosed with SSEH and invited them to complete the American Spinal Injury Association (ASIA) and Neuropathic Pain Symptom Inventory (NPSI) scales. Pearson χ2 and binary logistic regression were used to explore prognostic factors related to chronic pain after SSEH.

RESULTS

A total of 55 patients were reviewed; 21 patients (38.2%) were lost to follow-up, 3 patients (5.4%) died, and 31 patients (56.4%) completed the scales, with a mean follow-up time of 20.6 ± 17.3 months. The ASIA and NPSI results showed significant improvement after surgery. Pearson χ2 showed that timely surgery (≤ 12 h) was related to better outcomes (p < 0.05, Fisher test), and binary logistic regression revealed that patients with a preoperative NPSI score of 11-20 were prone to achieving significant pain relief (OR 23.67, 95%CI 1.11-503.48, p = 0.04).

CONCLUSION

Chronic pain is a common symptom during follow-up after SSEH, and timely intervention is suggested to obtain satisfactory outcomes. Patients who receive emergent surgery within 12 h or who have a preoperative NPSI score of 11-20 may achieve significant relief of chronic pain.

Stroke-like manifestation of a spontaneous spinal epidural hematoma with spontaneous resolution: a case report

BACKGROUND

This case report presents the case of a man with no known coagulopathy or preceding trauma, who spontaneously developed a spinal epidural hematoma (SEH). This is an uncommon condition which can have variable presentations including hemiparesis mimicking stroke, resulting in the potential for misdiagnosis and inappropriate treatment.

CASE PRESENTATION

A 28-year-old Chinese male with no past medical history presented with sudden onset neck pain associated with bilateral upper limbs and right lower limb subjective numbness but intact motor function. He was discharged after adequate pain relief but re-attended the emergency department with right hemiparesis. A magnetic resonance imaging of his spine revealed an acute cervical spinal epidural hematoma at C5 and C6. While admitted, he had spontaneous improvement of his neurological function and was eventually managed conservatively.

CONCLUSIONS

SEH, although uncommon, can be a mimic of stroke and it is important to avoid misdiagnosis as it is a time critical diagnosis, and administration of thrombolysis or antiplatelets can lead to unfavourable outcomes. Having a high clinical suspicion can help to guide us in the choice of imaging and interpretation of subtle signs to reach the correct diagnosis in a timely manner. Further research is required to better understand the factors that would favour a conservative approach as opposed to surgical treatment.

Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications

PURPOSE

Spontaneous spinal epidural hematoma (SSEH) is a rare but disabling disease. Although several cases have been reported in the literature, their treatment remains unclear, especially in patients with advanced age. We, therefore, aimed to describe the clinical outcomes of cervical SSEH in octogenarians with an acute onset of neurological illness undergoing laminectomy.

METHODS

Electronic medical records from a single institution between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, functional status, surgical characteristics, complications, hospital course, and 90-day mortality were also collected.

RESULTS

Twenty-two patients aged ≥ 80 years with SSEH undergoing laminectomy were enrolled in this study. The mean Charlson comorbidity index was 9.1 ± 2.0, indicating a poor baseline reserve. Ten individuals (45.5%) were taking anticoagulant agents with a pathologic partial thromboplastin time (PTT) of 46.5 ± 3.4 s. Progressive neurological decline, as defined by the motor score (MS), was observed on admission (63.8 ± 14.0). The in-hospital and 90-day mortality were 4.5% and 9.1%, respectively. Notably, the MS (93.6 ± 8.3) improved significantly after surgery (p < 0.05). Revision surgery was necessary in 5 cases due to recurrent hematoma. Anticoagulant agents and pathological PTT are significant risk factors for its occurrence. Motor weakness and comorbidities were unique risk factors for loss of ambulation.

CONCLUSIONS

Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits. Emergent surgery seems to be the "state of the art" treatment for SSEH. However, potential complications associated with adverse prognostic factors, such as the use of anticoagulants, should be considered.

Neurological severity evaluation using magnetic resonance imaging in acute spontaneous spinal epidural haematomas

PURPOSE

This study aimed to elucidate the severity of neurological deficits in a large series of patients with acute spontaneous spinal epidural haematoma (SSEH) using magnetic resonance imaging (MRI).

METHODS

We included 57 patients treated for acute SSEH at 11 institutions and retrospectively analysed their demographic and MRI data upon admission. We investigated MRI findings, such as the haematoma length and canal occupation ratio (COR). The neurological severity of SSEH was assessed based on the American Spinal Injury Association score on admission.

RESULTS

Of the 57 patients, 35 (61%) presented with severe paralysis. The MRI analysis showed that SSEH was often located in the cervical spine, dorsal to the spinal cord, and spread over more than three vertebrae. No differences in age, sex, and aetiology were found between patients with and without severe paralysis. The hypo-intensity layer encircling the haematoma, intra-haematoma heterogeneity, and increased CORs were observed more frequently in the severe paralysis group. Furthermore, pathological examination of a dissected haematoma from one patient with a hypo-intensity layer revealed a collagen layer around the haematoma, and patients with intra-haematoma heterogeneity were more likely to have a bleeding predisposition.

CONCLUSIONS

In this large series of patients with SSEH, we identified some MRI features associated with severe paralysis, such as the hypo-intensity layer, intra-haematoma heterogeneity, and increased COR. Accordingly, patients with these MRI characteristics should be considered for early surgical intervention.

Delayed postoperative spinal epidural hematoma after anterior cervical discectomy and fusion: A case report

Background

Postoperative spinal epidural hematoma (POSEH) causes rapid neurological deficits within 24 h following the operation and can be fatal. However, some POSEH symptoms manifest three days after the operation, also known as delayed POSEH (DPOSEH). Little attention has been provided upon DPOSEH owing to its rare incidence, resulting in serious consequences upon occurrence. To date, no cases of delayed POSEH after anterior cervical surgery have been reported.

Case presentation

We describe a case of DPOSEH that presented with delayed neurological deficits on the fifth day after anterior cervical discectomy and fusion (ACDF) surgery. Methylprednisolone was administered but showed no efficacy. MR revealed low T1 and strip long T2 signals located behind discs. After emergency surgical decompression, the patient's muscle strength returned to the preoperative state. However, his muscle strength decreased again on the seventh postoperative day, and the patient's family refused further surgery. Nine months after ACDF, the patient died of septic shock and respiratory failure.

Conclusions

DPOSEH can occur after three days or more following anterior cervical surgery; hence, monitoring of neurological function is suggested to be extended. Complete evaluation of risk factors, timely recognition, and differentiation of neurological symptoms are required for spine surgery. In the case of DPOSEH, methylprednisolone can be administered reasonably during the transition period. However, if there is no resolution of symptoms, emergency surgery should be performed as soon as possible.

Prognostic factors for spontaneous spinal epidural hematoma: a multicenter case-control study

BACKGROUND

To determine the optimal treatment for spontaneous spinal epidural hematoma (SSEH). The aim of this study was to identify factors associated with SSEH.

METHODS

In 62 patients with SSEH, several patient-related parameters were analyzed as candidate factors associated with Frankel grade before treatment or at the last follow-up. These parameters were compared between patients with and without surgery. In addition, multivariate ordinal logistic regression analysis was used to identify factors significantly associated with Frankel's grade before treatment or at the last follow-up.

RESULTS

There were significant differences in age, location of the hematoma, and Frankel grade before treatment and at the last follow-up between surgical and nonsurgical cases in all patients, but there were no significant differences in any of these parameters when comparing patients with pre-treatment Frankel grade C. The location of the hematoma was significantly associated with the severity of paralysis before treatment. In surgical cases, the time from onset to surgery and the location of the hematoma was significantly associated with the prognosis. When the time from onset to surgery was evaluated using the criteria of 12, 24, and 48 h, 24 and 48 h had a significant impact on the prognosis. In the analysis of nonsurgical cases, only the vertical size of the hematoma was significantly associated with prognosis.

CONCLUSION

The time from onset to surgery and the location of the hematoma were prognostic factors in surgical cases, while the vertical size of the hematoma was a prognostic factor in nonsurgical cases.

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

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.

Post-traumatic spinal hematoma in ankylosing spondylitis

PURPOSE

The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients.

METHODS

A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports.

RESULTS

Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate.

CONCLUSIONS

Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

Acute Spontaneous Cervical Spinal Epidural Haematoma a Very Rare Presentation Mimicking of Carotid Dissection during Sleep

Acute spontaneous spinal epidural hematoma without any identified etiology is a rare phenomenon and an uncommon cause of acute spinal cord compression. We report a case of acute spontaneous cervical spinal epidural hematoma, with sudden onset of acute neck pain and left-side body weakness during sleep which resembling of cervicle carotid dissection. The pain commenced suddenly, early in the morning while the patient was asleep. He had no previous history of any relevant medical disorder. Cervical Spine MRI revealed a cervical epidural haematoma at C3/C4, mainly on the left side, with spinal cord compression. Therefore, an emergent C3/C6 hemilaminectomy and evacuation of hematoma were carried out within 24 h of presentation. The patient's neck pain resolved after surgery and he was able to walk, though he required bladder catheterization on discharge after 1 week. He has nearly intact motor neurological examination in the second month of the operation.

Spontaneous Spinal Epidural Hematoma in a Patient on Apixaban for Nonvalvular Atrial Fibrillation

Background

With the rise in the use of direct oral anticoagulants (DOACs), more hemorrhagic complications are being encountered. Since the first description of a case of spontaneous spinal epidural hematoma (SSEH) related to the utilization of DOACs in 2012, there have been few reports describing a similar association. However, no cases so far have reported an association between SSEHs and apixaban. Case Description: A 76-year-old lady, with a history of nonvalvular atrial fibrillation, presented with a new onset of progressive left lower and upper extremity weakness. She reported back pain and numbness in the left leg up to the knee along with numbness in the left arm up to the shoulder. A CT scan of the neck was suggestive of an epidural hematoma extending from C2-C3 level to C6-C7. As the patient was on apixaban at the time, surgical treatment was delayed for two days to decrease the risk of intraoperative bleeding. Nine days later, she was discharged. Her physical exam was almost unchanged from that on presentation, except for resolution of pain and minimal improvement in motor power in her left lower extremity from 1/5 to 2/5 distally.

Conclusions

Spinal hematomas represent surgical emergencies with earlier intervention portending better outcome. Based on the few case reports that point to DOACs as a potential culprit, it appears that a high suspicion index resulting in earlier SSEH diagnosis and intervention is crucial for improved neurological outcome and recovery. Prompt diagnosis remains a challenge, especially that SSEH can mimic cerebrovascular accidents.

Spontaneous spinal epidural haematoma following intra-arterial catheter-directed thrombolysis: A case report

A 79-year-old Chinese gentleman presented with unilateral acute lower limb ischaemia and received intra-arterial catheter-directed thrombolysis, initially with good result and reversal of the ischaemia. However, he developed an extensive spontaneous spinal epidural haematoma within hours of the procedure and was left with permanent paraplegia after being deemed unsuitable for decompressive spinal surgery. This report serves as a reminder of the risk of severe complications of catheter-directed thrombolysis by describing this rare but devastating side-effect that occurred even despite early detection from onset of symptoms.

Isolated Retrodental Epidural Hematoma Without Dens Fracture

BACKGROUND

Traumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being < 1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma.

CASE REPORT

A 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.

Spontaneous resolution and complete recovery of spontaneous cervical epidural hematoma: Report of two cases and literature review

OBJECTIVE

To present the natural course and treatment modalities of spontaneous cervical epidural hematoma (SCEH), by reporting two rare cases with spontaneous resolution in both clinical and radiologic findings without surgery.

MATERIAL AND METHODS

One patient presenting with acute right side hemiparesis and another showing pure cervical radiculopathy were diagnosed with SCEH on magnetic resonance imaging (MRI). Both were both treated non-operatively. We also conducted a literature review of 19 cases of spontaneous spinal epidural hematoma (SSEH).

RESULTS

These two patients achieved complete resolution in terms of both neurologic function and radiologic findings within 21 days after onset. In the literature review, 63.2% of cases experienced neurologic improvement in the first 24h, 78.9% achieved complete neurologic recovery within 1 month, and radiological images showed complete resolution of hematoma in the first month for 73.7% of patients.

CONCLUSIONS

Atypical cervical SSEH can mimic cerebral stroke or a ruptured cervical disc. A high index of clinical suspicion followed by MRI examination is critical for diagnosis. Prompt surgical decompression and evacuation of the hematoma is generally regarded as first-line treatment. However, for patients without or with only slight neurologic symptoms, or showing early and sustained neurologic improvement, non-surgical therapy with close observation is a viable alternative. Both neurologic and radiologic resolution can be expected within the first month following onset in most cases of spontaneous resolution of SSEH.

Refracture of Kummell Disease Combined with Huge Epidural Hematoma After Minor Trauma

BACKGROUND

Kummell disease is defined as avascular necrosis of vertebra, occurs after the delayed posttraumatic osteoporotic vertebral collapse, and mainly occurs in adults older than 50 years of age. We report the first case of refracture of Kummell disease and epidural hematoma followed by paraparesis.

CASE DESCRIPTION

A 67-year-old woman with a known case of osteoporotic T12 fracture (3 months back) visited our outpatient clinic complaining of persistent back pain and paraparesis after jerking while getting up from the bed. Her neurology worsened suddenly in the next 2 days. A physical examination revealed grade 3 power in lower extremities with a lower extremity paresthesia and diminished bilateral knee and ankle reflexes. Urinary retention was also present. A plain radiographic examination of her thoracolumbar spine revealed osteoporotic compression fractures with almost 50% reduction in height of the 12th thoracic vertebra. Magnetic resonance imaging showed dorsal epidural soft tissue mass that caused posterior compression of the spinal cord at the T12-L3 levels. We performed thoracic lateral retropleural corpectomy and cage insertion at T12. Bone cement-augmented pedicle screw fixation was performed at the T10, T11, and L1 levels with laminectomy and decompression of hematoma at the T12, L1, L2, and L3 levels as a stage 1 procedure.

CONCLUSIONS

Although rare, the possibility of refracture of Kummell disease and spinal epidural hematoma should be kept in mind in patients with osteoporotic fractures. Periodic follow-up and treatment are essential for preventing tragic neurologic impairment.

Rapid Recovery of Spontaneous Spinal Epidural Hematoma without Surgical Treatment: Case Report and Literature Review

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a relatively uncommon yet potentially disabling neurologic emergency. The classical presentation includes a severe acute attack, sometimes radiating pain at the back, interscapular, or neck areas, followed by neurologic deficits. The main treatment is surgical, and self-healing cases are rare.

CASE DESCRIPTION

A 17-year-old female was admitted to the neurosurgery department with neck pain, myasthenia of the limbs, and difficulty moving. Mild neck pain had developed 1 week prior with no obvious predisposing causes. The patient had suddenly suffered severe neck pain during normal walking and developed rapid paralysis of her limbs. There was no recent history of trauma, infection, or drug administration. Magnetic resonance imaging performed 1 hour after the onset of limb paralysis demonstrated a large spinal epidural hematoma that extended from C4 to C6. However, 9 hours after the initial onset of severe neck pain, her symptoms completely ceased. Magnetic resonance imaging demonstrated that the SSEH had nearly dissipated.

CONCLUSIONS

Most cases of SSEH with spontaneous resolution are located on the upper thoracic and cervical spine. Surgery is the standard of care for these patients but can occasionally be deferred if the patient demonstrates significant rapid improvement.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report

Background

Spontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period.

Case presentation

We present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach.

Conclusions

The case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.

Successful treatment of traumatic spinal epidural haematoma with fluoroscopically-guided percutaneous drainage: a report of two cases

We report two cases of spinal epidural haematoma that were successfully treated with percutaneous drainage. The patients initially presented with severe backache and progressive neurological symptoms due to traumatic epidural haematoma. After fluoroscopically-guided percutaneous drainage and irrigation, rapid physical decompression and full recovery was observed in both patients. To the best of our knowledge, this is the first report indicating that traumatic spinal epidural haematoma can be successfully treated with fluoroscopically-guided percutaneous drainage. Because percutaneous puncture under fluoroscopy is less invasive than surgery, we recommend considering this procedure as a non-operative treatment option for epidural haematoma.

Puerperal ventral epidural hematoma after epidural labor analgesia

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.

Clinical Features, Management, and Prognostic Factors of Spontaneous Epidural Spinal Hematoma: Analysis of 24 Cases

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.

Spontaneous spinal epidural hematoma management: a case series and literature review

OBJECTIVE

Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH's 5.7% mortality-which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH's progression, outlining a best-practice therapeutic approach.

MATERIALS AND METHODS

Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines.

RESULTS

Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare-only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts.

DISCUSSION

The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

[Warfarin-associated epidural hematoma with spinal cord compression]

Hemorrhages into the structures of the central nervous system are the most life threatening among warfarin-associated complications. There are extremely few reports about spontaneous spinal epidural hematomas (SEH) associated with warfarin, methods of their timely diagnosis, treatment approaches. The authors present the first in the domestic literature case-report of warfarin-associated spontaneous SEH and the literature review.

Large, spontaneous spinal subdural-epidural hematoma after epidural anesthesia for caesarean section: Conservative management with excellent outcome

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.

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.

Spinal fractures in patients with ankylosing spondylitis

The ankylosed spine is prone to fracture even after minor trauma due to its changed biomechanical properties. The two central features of ankylosing spondylitis (AS) that promote the pathological remodeling of the spine are inflammation and new bone formation. AS is also associated with osteoporosis that is attributed to an uncoupling of the bone formation and bone resorption processes. Therefore, bone resorption occurs and promotes weakening of the spine as well as increased risk of vertebral fractures which can be hugely different in terms of clinical relevance. Even in the presence of symptomatic clinical vertebral fractures, the diagnosis can be overruled by attributing the pain to disease activity. Furthermore, given the highly abnormal structure of the spine, vertebral fracture diagnosis can be difficult on the basis of radiography alone. CT can show the fractures in detail. Magnetic resonance imaging is considered the method of choice for the imaging of spinal cord injuries, and a reasonable option for exclusion of occult fractures undetected by CT. Since it is equally important for radiologists and clinicians to have a common knowledge base rather than a compartmentalized view, the aim of this review article was to provide the required clinical knowledge that radiologists need to know and the relevant radiological semiotics that clinicians require in diagnosing clinically significant injury to the ankylosed spine.

Spontaneous spinal epidural hematoma management with minimally invasive surgery through tubular retractors: A case report and review of the literature

To report a minimally invasive paraspinal approach in the treatment of a case of spontaneous spinal epidural hematoma (SSEH). We additionally aim to review the relevant literature to enhance our knowledge of this disease. SSEH is an uncommon but potentially catastrophic disease. Currently, most appropriate management is emergence decompression laminectomy and hematoma evacuation. An 81-year-old woman was admitted to the neurology department with a chief complaint of bilateral numbness and weakness of the lower limbs and difficulty walking for 4 days with progressive weakness developed over the following 3 days accompanied with pain in the lower limbs and lower back. No history of trauma was reported. Magnetic resonance imaging of the thoracolumbar spine demonstrated an epidural hematoma extending from T-12 to L-5 with thecal sac and cauda equina displacement anterior. The patient was treated in our department with a minimally invasive approach. This operation method had been approved by Chinese Independent Ethics Committee. Three months following the operation, the patient had regained the ability to walk with the aid of a cane and myodynamia tests revealed normal results for the left lower limb and a 4/5 grade for the right limb. Importantly, no complications were exhibited from the surgical operation. The minimally invasive paraspinal approach through tubular retractors is demonstrated here as an effective alternative method for the treatment of SSEH.

Traumatic extradural lumbar haematoma due to a pathological metastatic vertebral body fracture L3. Case report and review of the literature

Spinal epidural haematoma (SEH) is a rare entity. We present the case of a 45 years old patient with lumbar epidural hematoma produced by a L3 vertebral tumoral (metastatic) fracture. Neurological status: cauda equina syndrome with sphincterian deficits, incomplete paraplegia (Frankel C), with neurological level L1. Emergency surgery was performed (L3-L2-bilateral laminectomy, L1 left laminectomy, posterior stabilization L2-L4 by titan screws) offering the possibility to progressive motor, sensitive and sphincterian deficites recovery.

Abbreviations: Computer Tomography-CT, Magnetic resonance Imaging-MRI, Spinal epidural haematoma-SEH, Visual analogue scale of pain-VAS.

Conclusion: We present a patient with a compressive subacute extradural haematoma, due to a traumatic fracture on a vertebral metastatic tumor who produced cauda equina syndrome. Surgical emergency intervention was mandatory for a good neurological outcome.

Spontaneous spinal epidural haematoma

Spontaneous spinal epidural haematoma (SSEH) is a rare clinical condition with unknown aetiology. Prompt diagnosis and treatment are paramount because of the risk of permanent neurological deficits without appropriate intervention. We described a case of a 48-year-old man presenting with complete quadriplegia and hypoesthesia. Magnetic resonance imaging revealed cervical cord compression due to a haematoma posterior to the spinal cord. Surgical decompression and evacuation of the haematoma was performed within 12 hours after admission to the authors' hospital. Both the patient's motor and sensory functions recovered soon after the operation. Early surgical decompression for SSEH with neurologic impairment is therefore recommended for the recovery of this patient and also serves as a relevant reference for orthopaedic clinics.

Foundation number: CXZZ20140414170821148.

Spontaneous cervical epidural hematoma with hemiparesis mimicking cerebral stroke

Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding.

Extensive long-segment cervicothoracic traumatic spinal epidural hematoma with avulsion of C7, C8, and T1 nerve roots

Traumatic spinal epidural hematoma (TSEH) is of rare clinical occurrence. We report a case of a young man with posttraumatic long-segment spinal epidural hematoma. Evacuation of the hematoma led to complete neurologic recovery in our patient. Our case highlights the importance of early diagnosis and prompt surgical intervention for the evacuation of hematoma in preservation or maximum recovery of neurologic function. Imaging findings, management options, and the relevant literature are reviewed.

Cervical epidural haematoma causing Brown-Sequard syndrome: a case report

Brown-Sequard syndrome secondary to compression of the spinal cord by an epidural haematoma following minor trauma is rare. A 65-year-old woman presented with neck pain and sudden onset hemiplegia with contralateral anaesthesia. Magnetic resonance imaging showed a haematoma in the epidural space in the C3 to C5 levels. She underwent open-door laminoplasty for evacuation of the haematoma. At the 2-year follow-up, she had regained normal sensations and a neurological grade of 5/5.

Clinical Outcomes of Spontaneous Spinal Epidural Hematoma : A Comparative Study between Conservative and Surgical Treatment

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.

Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature

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.

Spontaneous resolution of nontraumatic acute spinal subdural hematoma

Spinal subdural hematoma (SSDH) is an extremely uncommon condition. Causative factors include trauma, anticoagulant drug administration, hemostatic disorders, and vascular disorders such as arteriovenous malformations and lumbar punctures. Of SSDH cases, those that do not have any traumatic event can be considered cases of nontraumatic acute spinal subdural hematoma, which is known to have diverse clinical progress. Treatment typically consists of surgical decompression and cases in which the condition is relieved with conservative treatment are rarely reported. We report two nontraumatic acute spinal subdural hematoma patients who were successfully treated without surgery.

Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

METHODS

Case report and literature review.

FINDINGS

A previously healthy man presented with Brown-Séquard syndrome below T5-T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

CONCLUSIONS

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.

Chronic Spinal Epidural Hematoma Related to Kummell's Disease

Chronic spinal epidural hematoma related to Kummell's disease is extremely rare. An 82-year-old woman who had been managed conservatively for seven weeks with the diagnosis of a multi-level osteoporotic compression fracture was transferred to our institute. Lumbar spine magnetic resonance images revealed vertebral body collapse with the formation of a cavitary lesion at L1, and a chronic spinal epidural hematoma extending from L1 to L3. Because of intractable back pain, a percutaneous vertebroplasty was performed. The pain improved dramatically and follow-up magnetic resonance imaging obtained three days after the procedure showed a nearly complete resolution of the hematoma. Here, we present the rare case of a chronic spinal epidural hematoma associated with Kummell's disease and discuss the possible mechanism.

Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel

An acute spontaneous spinal epidural hematoma (SSEH) is a rare spinal pathology. A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity. Magnetic resonance imaging revealed an epidural hematoma, and the patient underwent emergency hemilaminectomy for evacuation. However, the symptoms worsened, and complete paraplegia developed. A second procedure to remove the recurrent hematoma was performed. No vascular malformation or other possible cause for SSEH was found other than the aspirin and clopidogrel medication. This case report describes relapsed SSEH caused by the combination of aspirin and clopidogrel medication and urges caution in prescribing dual antiplatelet agents.

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.

Transient paraparesis as a consequence of spontaneous spinal epidural haematoma

A 78-year-old man presented to the accident and emergency department following sudden onset of back pain, with attendant loss of power and sensation in the lower half of his body and urinary retention. Onset occurred while he was seated in a chair and he fell as he tried to get up. Neurological examination revealed symmetrical lower motor weakness (MRC grade 4/5) in both lower limbs with downgoing plantar reflexes. There was a clear sensory boundary at D4 with loss of joint position and sensation to light touch below this level. Rectal examination was unremarkable. While a CT head scan was normal, spinal MRI showed multilevel disc desiccations in the dorsal and lumbar spine. Additionally, in the dorsal spine at D4/5, there was a thin plaque of epidural tissue representing an epidural haematoma. Within 48-72 h the patient gradually and spontaneously regained full power.