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Dang R, Issagholian L, Schmidt T, Raoufi P, Neeki CC, Neeki MM. Management of traumatic cervical epidural hematoma in patients on Xa-inhibitors: a case report and review of the literature. J Med Case Rep 2023; 17:488. [PMID: 37936238 PMCID: PMC10629042 DOI: 10.1186/s13256-023-04069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/05/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This unique case of traumatic CEH represents an even smaller subset of these cases. Management varies by symptom presentation, mechanism of injury, and other contraindications. CASE PRESENTATION This case presents a 32 year old African American female on an oral anticoagulant sustaining traumatic cervical hematoma after a motor vehicle collision. Patient complained of neck, abdominal, and back pain. Imaging revealed a cervical spinal hematoma at the level of C3-C6. This case discusses the management of CEH for the general population and in the setting of anticoagulation. CONCLUSION Management of each case of CEH must be carefully considered and tailored based on their symptom presentation and progression of disease. As the use of anticoagulation including factor Xa inhibitors becomes more prevalent, there is greater need to understand the detailed pathophysiological aspect of the injuries. Targeted reversal agents such as Prothrombin Concentrate can be used for conservative treatment. Adjunct testing such as thromboelastogram can be used to help guide management.
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Affiliation(s)
- Robert Dang
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Leo Issagholian
- California University of Science and Medicine, Colton, CA, USA
| | - Tegan Schmidt
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Pasha Raoufi
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Cameron C Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Michael M Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA.
- California University of Science and Medicine, Colton, CA, USA.
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, USA.
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Kumari B, Kharwar RK, Rao DSN, Prakash J. Anaesthetic management in a child with post-traumatic cervical epidural haematoma: A case study. Indian J Anaesth 2023; 67:S299-S300. [PMID: 38187962 PMCID: PMC10768904 DOI: 10.4103/ija.ija_368_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 01/09/2024] Open
Affiliation(s)
- Babli Kumari
- Department of Anesthesiology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Ramesh K. Kharwar
- Department of Intensive Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - D. S. N Rao
- Department of Anesthesiology and Critical Care Medicine, Samford Hospital, Ranchi, Jharkhand, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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Ren C, Zhu Q, Yuan H. Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods. Quant Imaging Med Surg 2021; 11:2499-2508. [PMID: 34079719 DOI: 10.21037/qims-20-962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary. Methods A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed. Results Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ2=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ2=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine. Conclusions We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.
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Affiliation(s)
- Cui Ren
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Qiao Zhu
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China
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Counselman FL, Tondt JM, Lustig H. A Case Report: The Challenging Diagnosis of Spontaneous Cervical Epidural Hematoma. Clin Pract Cases Emerg Med 2020; 4:428-431. [PMID: 32926704 PMCID: PMC7434283 DOI: 10.5811/cpcem.2020.5.47107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 01/30/2023] Open
Abstract
Introduction We present the case of a patient with a spontaneous cervical epidural hematoma that presented with neck pain and mild, left arm parasthesia. Case Report A 59-year old man presented with sudden onset of severe neck pain, without history of injury or trauma. The patient also complained of associated left arm parasthesias that progressed to left arm and leg weakness while in the emergency department. Multiple diagnoses were considered and worked up; eventually the correct diagnosis was made with magnetic resonance imaging of the cervical spine. Conclusion Spontaneous cervical epidural hematoma typically presents with neck pain, and variable neurologic complaints. This case illustrates the challenge in making this uncommon but serious diagnosis.
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Affiliation(s)
- Francis L Counselman
- Eastern Virginia Medical School, Department of Emergency Medicine, Norfolk, Virginia.,Emergency Physicians of Tidewater, Norfolk, Virginia
| | - Julie M Tondt
- Eastern Virginia Medical School, Department of Emergency Medicine, Norfolk, Virginia
| | - Harry Lustig
- Eastern Virginia Medical School, Department of Emergency Medicine, Norfolk, Virginia.,Emergency Physicians of Tidewater, Norfolk, Virginia
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Roquilly A, Vigué B, Boutonnet M, Bouzat P, Buffenoir K, Cesareo E, Chauvin A, Court C, Cook F, de Crouy AC, Denys P, Duranteau J, Fuentes S, Gauss T, Geeraerts T, Laplace C, Martinez V, Payen JF, Perrouin-Verbe B, Rodrigues A, Tazarourte K, Prunet B, Tropiano P, Vermeersch V, Velly L, Quintard H. French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury. Anaesth Crit Care Pain Med 2020; 39:279-289. [PMID: 32229270 DOI: 10.1016/j.accpm.2020.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.
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Affiliation(s)
- A Roquilly
- Anaesthesiology and Intensive Care Unit, Hôtel-Dieu, Nantes University Hospital, Nantes, France.
| | - B Vigué
- Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - M Boutonnet
- Hôpital d'instruction des armées Percy, Clamart, France
| | - P Bouzat
- Grenoble Alps Trauma Centre, Department of Anaesthesia and Critical Care, Grenoble University Hospital, Grenoble, France
| | - K Buffenoir
- Neurosurgery department, Nantes University Hospital, Nantes, France
| | - E Cesareo
- Edouard-Herriot University Hospital, Lyon, France
| | - A Chauvin
- Anaesthesiology and Intensive Care Unit, Lariboisière Hospital, AP-HP, Paris, France
| | - C Court
- Orthopaedic Surgery Department, Spine and Bone Tumor Unit, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
| | - F Cook
- Unité de réanimation chirurgicale polyvalente et de polytraumatologie, Albert-Chenevier-Henri-Mondor University Hospital, Créteil, France
| | - A C de Crouy
- Unité SRPR/Réanimation chirurgicale, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
| | - P Denys
- Orthopaedic department, Spine and Bone Tumor Unit. Bicêtre University Hospital, Le Kremlin Bicêtre, France
| | - J Duranteau
- Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - S Fuentes
- Aix-Marseille University, AP-HM, Department of Neurosurgery, University Hospital Timone, Marseille, France
| | - T Gauss
- Post-Intensive Care Rehabilitation Unit, Bicêtre University Hospital, Le Kremlin Bicêtre, France
| | - T Geeraerts
- Anaesthesiology and Critical Care Department, Toulouse University Hospital, University of Toulouse 3-Paul Sabatier, Toulouse, France
| | - C Laplace
- Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - V Martinez
- Neuro Urology Unit, Department of Physical Medicine and Rehabilitation. Raymond Poincaré University Hospital, Garches, France
| | - J F Payen
- Department of Anaesthesia and Critical Care, Grenoble Alps University Hospital, 38000 Grenoble, France
| | - B Perrouin-Verbe
- Department of Neurological Physical Medicine and Rehabilitation, Nantes University Hospital, Nantes, France
| | - A Rodrigues
- Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - K Tazarourte
- Emergency department, Edouard-Herriot University Hospital, 69003 Lyon, France
| | - B Prunet
- Department of Anaesthesia and Critical Care, Val-de-Grâce Hospital, Paris, France
| | - P Tropiano
- Aix-Marseille University, AP-HM, Orthopaedic and traumatic surgery, University Hospital Timone, Marseille, France
| | - V Vermeersch
- Anaesthesiology and Intensive Care Unit, Brest University Hospital, Brest, France
| | - L Velly
- Aix Marseille University, AP-HM, Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | - H Quintard
- Intensive Care Unit, Nice University Hospital, Pasteur 2 Hospital, Nice, France
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Naeem A, Hanson J, Freebody J, Schutz A, O'Brien B. Spontaneous cervical epidural haematoma-diagnosis as unexpected finding by CT: case series. Quant Imaging Med Surg 2020; 9:1986-1991. [PMID: 31929971 DOI: 10.21037/qims.2019.10.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Adil Naeem
- Department of Radiology, Gosford Hospital, Gosford, Australia
| | - Julian Hanson
- Department of Radiology, Gosford Hospital, Gosford, Australia
| | - John Freebody
- Department of Radiology, Gosford Hospital, Gosford, Australia
| | - Anna Schutz
- Department of Neurology, Gosford Hospital, Gosford, Australia
| | - Bill O'Brien
- Department of Neurology, Gosford Hospital, Gosford, Australia
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Yin R, Chang P, Zhu Q, Cheng F, Zhao B, Gu R, Zhang BY. Thoracolumbar traumatic nucleus pulposus sequestration combined with a slight flexion distraction fracture: A rare case report and literature review. Medicine (Baltimore) 2018; 97:e10952. [PMID: 29923980 PMCID: PMC6024002 DOI: 10.1097/md.0000000000010952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
RATIONALE Traumatic nucleus pulposus sequestration (TNPS) usually occurs concurrently with severe destruction of bone. TNPS combined with a slight thoracolumbar flexion- distraction fracture, triggering a disastrous nerve injury, has rarely been reported. Due to the atypical radiologic manifestations, such a patient can easily be overlooked. PATIENT CONCERNS Hereby, we present a TNPS patient as well as a slight thoracolumbar flexion-distraction fracture and serious neurologic symptoms. DIAGNOSES T12 spinous process fracture, L1 flexion distraction fracture, thoracolumbar traumatic nucleus pulposuse sequestration and lower limbs incomplete paralysis INTERVENTIONS:: To avoid further neurologic compromise, an urgent laminectomy and exploration of the spinal canal was performed. OUTCOMES After decompression OR and 4 months rehabilitation, the patient's neurologic function improved remarkably. LESSONS A slight flexion-distraction fracture following injury is liable to eclipse the concurrence of TPNS. For this patient, a high-resolution MRI was needed to make a definitive diagnosis and guide surgery. Once TPNS has been diagnosed, sufficient decompression and discectomy surgery should be performed without delay.
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Affiliation(s)
- Ruofeng Yin
- Orthopaedics Surgery Department, China-Japan Union Hospital of Jilin University
| | - Pengyu Chang
- Radiotherapy Department, First Bethune Hospital of Jilin University
| | - Qingsan Zhu
- Orthopaedics Surgery Department, China-Japan Union Hospital of Jilin University
| | - Fei Cheng
- Pathology Department, China-Japan Union Hospital of Jilin University, Jilin Province, China
| | - Baolin Zhao
- Orthopaedics Surgery Department, China-Japan Union Hospital of Jilin University
| | - Rui Gu
- Orthopaedics Surgery Department, China-Japan Union Hospital of Jilin University
| | - Bo-Yin Zhang
- Orthopaedics Surgery Department, China-Japan Union Hospital of Jilin University
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