A spontaneous spinal epidural hematoma in a hemodialysis patient: a rare entity

Spontaneous spinal epidural haematoma following COVID-19 vaccination: a case report

Introduction

COVID-19 vaccination side effects are rare but important medical situations. Spine-affecting side effects are amongst the rarest, but exceedingly important. Haemorrhagic spinal manifestations of COVID-19 and its vaccines are less reported with little knowledge about them.

Case presentation

An 80-year-old male who received his first shot of the COVID-19 vaccine had developed COVID-19 pneumonia, weakness, and sensory problems in his legs followed by sphincter incontinence within 5 days period. MRI showed a spontaneous epidural spinal epidural haematoma (SSEDH) in T10-L1. He underwent laminectomy and haematoma evacuation. One month follow-up showed no clinical improvement.

Discussion

To our knowledge, this was the first post-vaccination SSEDH and second in haemorrhagic spinal complications following COVID-19 vaccination. Considering the neuropathogenesis pathway of COVID-19 and its vaccines, there are common mechanisms of action that could potentially justify post-vaccination SSEDH such as seen in COVID-19 infection, itself. Early Neurosurgical intervention and better preoperative neurological status could be a beneficial modifier for favourable clinical outcomes.

Conclusion

SSEDH and COVID-19 vaccine coincidence is a rare clinical event, still no solid association could be scientifically explained. Further studies are required for a reliable pathophysiologic association. Early diagnosis, interdisciplinary medical approach, and faster intervention are the cornerstone of the treatment paradigm.

Spontaneous spinal epidural hematoma (SSEH) after cesarean section under epidural anesthesia: A case report

Spontaneous spinal epidural hematoma (SSEH) is an uncommon condition that can lead to severe neurological injuries, often accompanied by back pain. Pregnancy is identified as a risk factor for SSEH. Early diagnosis of SSEH presents challenges due to its atypical manifestations and the use of intraspinal anesthesia and analgesic techniques. In this case, we present the instance of a 29-year-old woman who initially received epidural labor analgesia during the first stage of labor but subsequently required a cesarean section under epidural anesthesia according to amniotic fluid turbidity. Unfortunately, the anomalous recovery of neurological function in her left lower extremity was not given sufficient attention at an early stage, and paralysis in the non-puncture segment occurred 45.5 hours after the initial puncture. Interestingly, she did not experience any back pain during these procedures. MRI examination and consultation with neurosurgeons confirmed the diagnosis of SSEH, prompting the patient to undergo emergency decompression surgery. She made an incomplete recovery 17 months after the operation. This case emphasizes the importance of considering the possibility of SSEH in pregnant women undergoing epidural analgesia, highlighting the need for spinal imaging and early neurosurgical interventions to facilitate treatment.

Spontaneous cervical epidural hematoma in a patient with end-stage renal disease

Spontaneous spinal epidural hematoma (SEH) is extremely rare in patients with end-stage renal disease (ESRD). We report a case of a 71-year-old man with ESRD presented with progressive left limb weakness. Magnetic resonance imaging (MRI) revealed spinal cervical SEH involving C3-5 level. The patient received emergent decompression laminectomy with the evacuation of the epidural hematoma.

Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review

BACKGROUND

Spontaneous spinal epidural hematomas (SSEH) are rare yet severe conditions. In pregnancy, this condition is challenging to diagnose and treat because of the risks to the mother and fetus. This study reviews the literature on SSEHs in pregnancy.

METHODS

We performed a systematic review of the English literature on SSEHs from 1990 until 2018. Outcome measures were mode of presentation, risk factors, initial neurologic findings, diagnostic investigations, site and size of the SSEH, treatment, neurologic recovery, and survival.

RESULTS

Fourteen publications (16 patients) were included. Two patients presented in the second trimester, with the remainder in the third trimester. All patients presented with back pain, and 15 subsequently developed spinal cord dysfunction. Magnetic resonance imaging (MRI) was performed in all cases. The cervicothoracic region was the most commonly affected, and the average hematoma size extended across 3.9 vertebral levels. All patients with neurologic dysfunction underwent surgical decompression. In women under 32 weeks' gestation, caesarean section was not routinely performed. In contrast, women of gestational age of 32 weeks or more underwent a caesarean section prior to spinal decompression. Women without neurologic dysfunction underwent a caesarean section and neurologic monitoring without decompression. All patients with abnormal neurology improved after surgery, except 1 patient. No patients died.

CONCLUSIONS

In pregnancy, SSEHs typically present in the second or third trimesters with back pain, predominantly in the cervicothoracic region, followed by progressive neurologic dysfunction. MRI is diagnostic, and the treatment depends on the patient's neurologic dysfunction and gestational age.

Spontaneous spinal epidural haematomas in children

PURPOSE

To understand the typical presentation, risk factors, location and size, treatment, neurological recovery and survival of spontaneous spinal epidural haematomas (SSEH) in children.

METHODS

A systematic review of the English literature from 1 January 1960 to 1 March 2018 was performed on children aged 18 years and younger. Individual patient data were extracted and collated. Outcome measures were mode of presentation, risk factors, initial neurological findings, initial presumed diagnosis, diagnostic investigations, site and size of the SSEH, treatment, neurological recovery and survival.

RESULTS

Thirty-one publications and 36 patients were reviewed. All age groups were affected. 83% of patients did not have a known risk factor. Back pain was reported in 61% and neurological dysfunction in 97% of patients, although not all articles defined these parameters. Initially 28% of patients were suspected of having an alternative diagnosis. All patients had an MRI and/or CT scan confirming the diagnosis. The cervical-thoracic region was most commonly affected, and the average haematoma size extended across 6.3 vertebral levels. Surgical decompression was performed in 72% of patients. Neurological function improved in 83% of patients. Two patients died as a consequence of their SSEH.

CONCLUSIONS

SSEHs affect all paediatric age groups and typically present with neurological dysfunction and/or back pain. The initial diagnosis is incorrect in up to 28% of cases, but cross-sectional spinal imaging is diagnostic. Most SSEHs are located in the cervico-thoracic region and affect multiple spinal levels. The treatment depends on whether the patient has a bleeding disorder and their neurological status. These slides can be retrieved under Electronic Supplementary Material.

Successful Recovery from Spontaneous Spinal Epidural Hematoma in a Patient Undergoing Hemodialysis

Patient: Male, 70

Final Diagnosis: Spontaneous spinal epidural hematoma

Symptoms: Abdominal pain • chest pain • complete paraplegia

Medication: —

Clinical Procedure: Conservative management

Specialty: Nephrology

Beware Neck Pain in a Haemodialysis Patient: Spontaneous Spinal Epidural Haematoma

Spontaneous spinal epidural haematoma is a rare and devastating disorder. To the best of our knowledge, only 4 haemodialysis patients with the diagnosis of spontaneous spinal epidural haematoma have been reported in the literature. Here, we reported a 70-year-old male haemodialysis patient who presented with a sudden onset of severe sharp neck pain. Spontaneous spinal epidural haematoma with cord compression from C2 to C6 was diagnosed by magnetic resonance imaging. After emergency surgery, the patient recovered completely from the profound neurological deficits. The relevant literatures were also reviewed.

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.

Spinal subdural abscess: a rare complication of decubitus ulcer

Spinal subdural abscess (SSA) is an uncommon entity. The exact incidence is unknown, with very few cases reported in the literature. This condition may result in spinal cord compression, thus constituting a medical and neurosurgical emergency. The pathogenesis of SSA is not well-described, and the available knowledge is based on case observations only. There is only one case report that describes direct seeding from decubitus ulcers as a possible mechanism for development of SSA. We report a case of subacute onset of quadriplegia in a male patient, age 55 years, due to spinal cord compression from SSA and superimposed spinal subdural hematoma. The direct seeding from decubitus ulcers is thought to be the cause of infection in our patient. We present this case of SSA to elucidate and review the predisposing factors, pathogenesis, clinical presentation, diagnostic modalities, and treatment regarding management of this rare disorder.

Whole spontaneous spinal epidural hematoma

A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.

Spontaneous spinal epidural hematoma after abrupt sneezing with prompt recovery of severe paraparesis

Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic condition with threatening consequences when spinal cord compression is present. The diagnosis must be performed quickly using magnetic resonance imaging (MRI), which shows collection of blood in the epidural space. With spinal cord compression, there is an indication for urgent surgical decompression. Here, we present a 64-year-old woman who developed sudden thoracic and lower back pain accompanied by severe paraparesis and urinary retention after sneezing abruptly. An MRI revealed a posterior thoracic epidural hematoma extending from the T6 to T11 vertebral level with spinal cord compression. Decompression was recommended, but the patient refused surgery, while neurologically improving with time. Complete neurologic recovery was observed within 24 hours after SSEH onset. A conservative therapeutic approach with careful observation may therefore be considered as a treatment of choice in some cases where surgery is refused, (due to high risk or other reasons) and neurologic recovery is early and sustained.

Spontaneous spinal epidural hematomas associated with acute myocardial infarction treatment

Many studies have reported spontaneous spinal epidural hematoma (SSEH). Although most cases are idiopathic, several are associated with thrombolytic therapy or anticoagulants. We report a case of SSEH coincident with acute myocardial infarction (AMI), which caused serious neurological deficits. A 56 year old man presented with chest pain accompanied with back and neck pain, which was regarded as an atypical symptom of AMI. He was treated with nitroglycerin, aspirin, low molecular weight heparin, and clopidogrel. A spinal magnetic resonance image taken after paraplegia developed 3 days after the initial symptoms revealed an epidural hematoma at the cervical and thoracolumbar spine. Despite emergent decompressive surgery, paraplegia has not improved 7 months after surgery. A SSEH should be considered when patients complain of abrupt, strong, and non-traumatic back and neck pain, particularly if they have no spinal pain history.

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.