A Spontaneous Spinal Epidural Hematoma Secondary to Long-Term Low-Dose Aspirin and Clopidogrel Use: A Case Report

The association between antiplatelet agents such as aspirin, clopidogrel, and ticlopidine and spontaneous spinal epidural hematoma is based on multiple case reports in the literature. Here, we present the case of a 76-year-old male patient who presented with acute low back pain associated with sudden-onset paralysis of the lower extremities. His past medical history was remarkable for coronary artery disease with a stent placement history on dual antiplatelet therapy including low-dose aspirin and clopidogrel. An extensive posterior thoracolumbar epidural hematoma was seen on the imaging test, and rapid clinical improvement was evident early during his presentation. This prompted a conservative approach that led to complete neurological recovery. This case is in line with limited English-language literature evidence that suggests a possible association between spontaneous spinal epidural hematoma and antiplatelet agents. We aim to enhance clinicians' awareness of this clinical entity, association, presentation, and management.

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.

Lumbar Intervertebral Disc Herniation Masquerading as an Epidural Hematoma: A Case Report and Review of the Literature

CASE

A 50-year-old man developed acute back and bilateral leg pain after minor trauma. Laboratory tests and routine radiographs were unremarkable. Magnetic resonance imaging (MRI) showed a 5 × 15 × 42-mm longitudinally oriented mass behind the L2-L3 interspace that obliterated the subarachnoid space and displaced the nerve roots. The mass was isointense on T1-weighted imaging and showed mixed low and high signals on T2-weighted imaging. Based on the clinical history and the imaging findings, a provisional diagnosis of spinal epidural hematoma (SEH) was made. A laminectomy was performed at L2-L3; intraoperatively, a large disc herniation was found at L2-L3, with no evidence of hematoma.

CONCLUSION

MRI findings of SEH and disc herniation have been well described in the literature. To our knowledge, this is the third report of intraoperatively confirmed disc herniation with MRI findings suggestive of SEH These discordant MRI and intraoperative findings illustrate that an SEH and a disc herniation may not always be distinguishable on MRI and may require surgical confirmation.

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.

Case Report: Thoracic Spinal Epidural Haematoma – an Unusual Cause of Chest Pain

Chest pain is a common presentation to the emergency department. Aetiologies to be considered are usually cardiac or pulmonary in origin. We reported a rare case of thoracic spinal epidural haematoma initially presenting to the emergency department with chest pain. The patient re-attended the emergency department four hours after discharge with symptoms of cord compression. Magnetic resonance imaging of the thoracic spine showed an epidural haematoma causing cord compression. Surgical decompression was performed with gradual resolution of symptoms. Simply ruling out acute coronary syndrome may not be sufficient in patients presenting with chest pain.

Spontaneous chronic epidural hematoma in the lumbar spine associated with Warfarin intake: a case report

INTRODUCTION

Spontaneous spinal epidural hematomas are rare. However, in patients on anticoagulant treatment the risk may increase. Symptomatically patients may present with radiculopathy and even progressive neurological deficits.

CASE DESCRIPTION

We present a case of a warfarin treated patient with left L5 radiculopathy. MRI was evaluated as showing a lumbar disc prolapse or synovial cyst at L4-L5 level. The patient was operated and an organized material was removed and analysed as a hematoma. No prolapsed disc or synovial cyst was found. The patient was neurologically restored following the operation.

DISCUSSION AND EVALUATION

This case illustrates how spontaneous epidural spinal hematomas can present with symptoms of radiculopathy and radiologically be misinterpreted as a protruding disc or cyst.

CONCLUSION

Warfarin treated patients may have an increased risk of spontaneous spinal epidural hematomas.

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.

Three cases of hemiplegia after cervical paraspinal muscle needling

BACKGROUND CONTEXT

Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood.

PURPOSE

We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications.

STUDY DESIGN

Case report.

METHODS

The authors retrospectively reviewed the medical charts from a decade (2002-2013) at Korea University Hospital. The records were systematically searched, and the cases with hemiplegia (grade<3) after needing therapy were collected. No conflict of interest reported. No funding received.

RESULTS

A 54-year-old woman, a 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture, or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially.

CONCLUSION

Spinal hematoma after muscle needling is unusual but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.

Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases

We report 2 cases of spontaneous spinal epidural haematoma after antiplatelet treatment. One patient was on ticlodipine therapy and the other was on aspirin and clopidogrel. Both diagnoses were made using magnetic resonance imaging. One patient underwent multilevel laminectomies and posterior spinal fusion within 24 hours of symptom onset and achieved complete neurological recovery. The other underwent unilateral hemilaminectomies 40 hours after symptom onset and did not show neurological improvement. A high index of suspicion is needed for patients presenting with severe lower back pain and rapid neurological deterioration, especially in those on antiplatelet therapy. Urgent spinal cord decompression and epidural haematoma cord evacuation may provide more favourable outcome.

Epidural Hematoma Related with Low-Dose Aspirin : Complete Recovery without Surgical Treatment

Hemorrhagic complications associated with aspirin use occur primarily at skin or gastrointestinal sites but can occasionally occur in the central nervous system. In particular, spontaneous spinal epidural hemorrhage (SSEH) associated with aspirin is very rare. We report a case of low-dose (100 mg daily) aspirin-related SSEH that was successfully treated with medical management. Our case indicates that low-dose aspirin could induce SSEH and that conservative treatment with close observation and repeated imaging studies should be considered in cases with neurological improvement or mild deficits.

Nontraumatic spinal epidural hematoma during pregnancy: diagnosis and management concerns

OBJECTIVE

Nontraumatic spinal epidural hematoma (SEH) during pregnancy is rare. Therefore, appropriate management of this occurrence is not well defined. The aim of this study was to extensively review the literature on this subject, to propose some novel treatment guidelines.

METHODS

Electronic databases, manual reviews and conference proceedings up to December 2011 were systematically reviewed. Articles were deemed eligible for inclusion in this study if they dealt with nontraumatic SEH during pregnancy. Search protocols and data were independently assessed by two authors.

RESULTS

In all, 23 case reports were found to be appropriate for review. The mean patient age was 28 years and gestational age was 33.2 weeks. Thirteen cases presented with acute interscapular pain. The clinical picture consisted of paraplegia, which occurred approximately 63 h after pain onset. Spinal cord decompression was performed within an average time of 20 h after neurological deficit onset. Fifteen patients had cesarean deliveries, even when the gestational age was less than 36 weeks.

CONCLUSION

This review failed to identify articles, other than case reports, which could assist in the formation of new guidelines to treat SEH in pregnancy. However, we believe that SEH may be managed neurosurgically, without requiring prior, premature, cesarean section.

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.

Cervical spontaneous spinal epidural hematoma with internal jugular vein thrombosis

Spontaneous spinal epidural hematoma (SSEH) is a rare condition, and its etiology remains unclear. Spinal venous wall instability due to intravenous pressure changes and the resultant venous rupture seem to be the underlying pathophysiological mechanisms. Here, the authors report a case of posterior SSEH at the C3-5 level causing mild left hemiparesis in a previously healthy 56-year-old woman. Angiography performed at the time of admission showed left internal jugular vein (IJV) thrombotic occlusion and dilation of the surrounding venous plexus, strongly suggesting that these pathologies caused the SSEH. Furthermore, immediate MR imaging suggested severely impaired blood flow in the left IJV. The hematoma soon resolved after spontaneous IJV thrombolysis. The authors' radiological observations imply that idiopathic IJV thrombosis may cause cervical SSEH.

Spinal epidural hematoma after pain control procedure

Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.

An unusually rapid spontaneous recovery in a patient with spinal epidural hematoma

BACKGROUND

Spontaneous epidural hematoma is a rare condition, which usually requires urgent surgical treatment.

OBJECTIVES

To report two cases of spontaneous epidural hematoma, one of which was treated conservatively, and the other surgically, and discuss the possibility of unusual spontaneous recovery and treatment decision-making.

CASE REPORT

We encountered 2 patients with spontaneous spinal epidural hematoma, both of whom were taking an anti-platelet agent, producing severe paraplegia. One patient with a hematoma at C2-T3 experienced a rapid neurological recovery while a magnetic resonance imaging scan was being performed. A complete resolution of the hematoma and complete neurological recovery ensued without surgical intervention. A second patient with a hematoma at T10-12 showed no neurological recovery up to the time emergency surgery started and was treated surgically by T10-12 laminectomy and excision of the hematoma. Neurological function returned to normal in both patients.

CONCLUSION

The occurrence of spontaneous recovery in some patients makes the decision for surgery difficult. Emergency physicians need to be aware of the possibility of spontaneous rapid neurological recovery in patients with spinal epidural hematoma. To avoid unnecessary surgery in patients who will spontaneously have neurological recovery, neurological evaluations need to be repeatedly performed up to the time the emergency surgery begins. However, unfortunately, there is no diagnostic tool at present to identify the patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results, therefore, conservative treatment should be prescribed only for those patients who exhibit improving neurological signs early in the clinical course.

Spontaneous spinal epidural haematoma in a 15-month-old boy presenting with a wry neck: a case report

A 15-month-old boy presented with a 2-day history of a wry neck (bent to the left side) with no definite trauma. He had bilateral upper limb weakness and was afebrile, conscious, and stable. There was no spontaneous movement in both upper limbs. Magnetic resonance imaging of the cervical and thoracic spine demonstrated an extensive spontaneous spinal epidural haematoma from C3 to T8. 23 hours after admission, the patient underwent an emergency right-sided C3 to T8 hemi-laminectomy and haematoma evacuation. The patent's strength gradually recovered and he attained full power 3 weeks after operation. Spontaneous spinal epidural haematoma is a rare disease in children. A high index of suspicion is essential for its effective management as the interval to operation is the most important prognostic factor.

Spontaneous spinal epidural hematoma: analysis of 23 cases

BACKGROUND

Spontaneous spinal epidural hematoma is a rare but disabling disease. To explore its characters and find out what factors influence the prognosis, we gave a retrospective analysis of 23 patients in our department in the past 8 years.

METHODS

Spontaneous spinal epidural hematoma was diagnosed by taking MRIs of patients without surgical management or by histopathological examination. We registered patient's case history, laboratory examination, radiological image, treatment, pathological result, and prognosis after 3 months and gave them nonparameter analysis.

RESULTS

Primary neurological status and progressive intervals have correlation with prognosis (P< .01), and the latter less than 12 hours predict worse prognosis (P= .032). Spinal edema in MRI predicts pessimistic prognosis (P= .013). Long hematoma predicts worse prognosis (P= .02). Preoperative interval, emphasized by other authors, has no statistical correlation with prognosis in this study (P= .832). Finally, patients with a single hematoma or hematoma mingled with other spinal disturbance have the same prognosis (P= .065).

CONCLUSIONS

The primary neurological status, progressive interval, spinal edema, and size of hematoma will influence the prognosis of the patient with SSEH. The major treatment is surgical intervention, and it should be operated as soon as possible to avoid the aggravation of neurological status. Conservative treatment is not considered unless patient's neurological deficiency has relieved in the early period.

Clopidogrel-induced spontaneous spinal epidural hematoma

The hemorrhagic side effects associated with the use of clopidogrel are within the acceptable range and occur mainly at skin or gastrointestinal sites. We report a case of spontaneous spinal epidural hematoma (SSEH) in a 60-yr-old woman who was treated with clopidogrel for frequent transient ischemic attacks. To our knowledge, this is the second reported case of clopidogrel-induced SSEH. The patient's symptoms and past history of clopidogrel use suggested the diagnosis and made the procedure proceed quickly to operate SSEH 9 hr after the onset of paraplegia. The outcome was excellent. Therefore, with the popularity of antiplatelet prescription, physicians should keep in mind and urgently treat this unusual but critical side effect.

[The spontaneous spinal epidural haematoma]

Spontaneous spinal epidural haematoma (SSEH) is a rare and serious condition. Four cases of SSEH are presented in this paper, three of which were in the cervical segment while one involved the entire spine. In two of these four cases the diagnosis was not made until late in the course, and persisting neurological deficits resulted; one case was diagnosed early and the neurological outcome was good; and in one the decompression achieved was inadequate, owing to intraoperative complications. Laminectomy was performed in all four cases for the purpose of decompression of the spinal cord but at different intervals after the onset of symptoms and with different neurological outcomes. The prognosis of SSEH depends heavily on the time that elapses between the onset of symptoms and the surgical treatment. The diagnostic procedure of choice is MRI.

Pure cervical radiculopathy due to spontaneous spinal epidural haematoma (SSEH): report of a case solved conservatively

INTRODUCTION

Spontaneous spinal epidural haematoma (SSEH) is widely recognised throughout the literature as a cause of myelopathy, radicular compression being very rarely reported. Surgical management is almost always recommended, especially in the cases of spinal cord compression. Conservative treatment is reported as a curiosity and only in the case of spontaneous improvement. This report presents the particular case of a 64-year-old patient undergoing anticoagulant therapy that had a cervical radiculopathy due to a SSEH confirmed by MRI. The patient improved spontaneously and symptoms were solved with unconventional conservative treatment and without stopping the anticoagulant therapy.

CONCLUSIONS

Spontaneous epidural haematoma must be kept in mind when patients undergoing anticoagulant therapy have a sudden onset of cervicobrachialgia. Even though most spinal surgeons advocate surgical treatment, a conservative approach may lead to a complete recovery and may be considered as a good option in the case of radicular involvement. Discontinuation of the anticoagulant therapy may not always be needed, especially when the clinical syndrome improves spontaneously.

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

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

Experience in the surgical management of spontaneous spinal epidural hematoma

OBJECT

Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity. Although many cases have been reported in the literature, controversy persists as to its origin, diagnosis, and timing of treatment. The authors conducted a study in patients treated in their hospital and report the results.

METHODS

Clinical data obtained in 35 patients with SSEH were retrospectively reviewed. Age, sex, history of hypertension, and history of anticoagulation therapy were recorded, and data were analyzed to clarify the possible predisposing factors of SSEH. Neurological outcomes were reappraised using a standardized grading system and correlated with the time interval from initial ictus to surgery, duration of complete neurological deficits, and the rapidity of deterioration of paralysis. Nonparametric methods and Spearman rank-correlation coefficients were used for statistical analysis.

CONCLUSIONS

Surgery is a safe and effective procedure to treat SSEH. The disease-related mortality rate was 5.7%, the surgery-related complication rate was 2.9%, and there were no operation-related deaths. Neurological outcome after surgery is positively correlated with preoperative neurological deficits (88.9% complete recovery in patients with incomplete neurological deficits compared with 37.5% in those with complete deficits [p < 0.001]). In patients in whom the time interval from initial ictus was shorter (< 48 hours) and in whom the duration of complete neurological symptoms was also briefer (< 12 hours), there is a positive correlation with better neurological and functional recovery (p < 0.05).

Revisión de 22 casos de hematomas epidurales espinales. Factores pronósticos y manejo terapéutico

INTRODUCTION

Spontaneous and non-spontaneous spinal epidural hematoma (SEH) is a rare condition in neurosurgical practice. It presents as an acute spinal cord compression and usually requires emergent surgical decompression. Recently non-surgical treatment (corticoid therapy) has been proposed in selected cases of SEH with good neurological recovery.

OBJECTIVES

To identify the prognostic factors of this condition. A treatment management based upon our results is proposed.

MATERIAL AND METHODS

Between 1985 and 2001, 22 patients suffering SEH were treated at our Department. Age, sex, initial neurological condition (evaluated using the Frankel grading scale), surgical timing, radiological data such as location, extension and degree of radiological cord compression, anticoagulation or antiplatelet therapy, epidural anesthesia and previous spinal surgery were analyzed in order to find prognostic factors. Finally, conservative or surgical treatment as well as final neurological condition were also considered for the analysis.

RESULTS

The average age was 69 years with a male preponderance (72.7%). Surgical decompression was done in 17 cases, most of them (11 cases) presenting with high neurological deficit (Frankel A-B). Conservative treatment was used on 5 patients. Operated patients showed a larger degree of neurological recovery. The incidence of post-operative complications was of 13%.

CONCLUSIONS

This study shows the efficiency of SEH surgical evacuation performed within the first 24 hours, particularly when the patient presents a severe neurological deficit (Frankel A-B). Patients presenting minimal neurological involvement (Frankel D-E) can be managed successfully with conservative treatment.

Multilevel acute spinal epidural hematoma in a patient with chronic renal failure--case report

A 47-year-old female with diabetic nephropathy presented with acute onset of severe back pain and progressive weakness in both lower extremities. Neuroimaging revealed a spinal epidural hematoma extending from the T-3 vertebra to the sacrum. Removal of all or every other lamina on levels with epidural hematoma and emergent evacuation of the hematoma were planned. T-9 and T-10 laminectomies were performed, but excessive bleeding during the operation prompted us to abandon the procedure. Plasma and desmopressin administration controlled the bleeding from the drain 8 hours after the operation. Follow-up neuroimaging one month later revealed total resolution of the hematoma with improved neurological status. Acute spinal epidural hematomas extending over more than 15 segments are extremely rare and the surgical treatment is still challenging. Coexisting hemorrhagic diathesis creates more problems. Conservative treatment may be the best option.

Spinal epidural haematoma: MRI-aided diagnosis

Spinal epidural haematoma is a rare cause of spinal cord compression. It is most commonly attributed to trauma and coagulation disorders. We report a case of a 64 year-old man with thrombocytopaenia who presented with a traumatic epidural haematoma who p resented with right hemiparesis which progressed to complete tetraplegia. MR of the cervical spine showed an epidural collection on the posterior aspect of the cord throughout the cervical spine. The patient underwent C1-C7 laminectomy and decompression. Postoperatively, the patient has improved gradually and has power of grade 3 (Medical Research Council classification of power) in all 4 limbs at 2-month follow-up. MRI is an important modality in the early diagnosis of spinal epidural haematomas and can facilitate emergent decompressive surgery which offers the best chance of neurological improvement.

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

STUDY DESIGN

Case report.

OBJECTIVE

To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment.

SUMMARY OF BACKGROUND DATA

The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause.

METHODS

One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery.

RESULTS

Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified.

CONCLUSIONS

Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.

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

Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.

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

OBJECTIVE AND IMPORTANCE

Demonstration of interest of medical treatment of cervical epidural hematomas.

CLINICAL PRESENTATION

A young patient developed cervical pain after experiencing cervical trauma. Computed tomography and magnetic resonance imaging demonstrated an epidural cervical hematoma. A spontaneous resolution of the clinical symptoms and the radiological abnormalities was observed.

CONCLUSION

Although surgical decompression is generally regarded as mandatory in selected patients with incomplete and nonprogressing deficits, conservative management may be possible.