Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation

A Rare Case of a Spontaneous Thoracic Epidural Hematoma in a Young Male Weightlifter

Spontaneous spinal epidural hematoma (SSEH) is the accumulation of blood in the epidural space of the spinal cord. Acute SSEH is a rare phenomenon that presents with a wide variety of neurologic symptoms and most often is a surgical emergency. We present a previously healthy 34-year-old male with sudden onset progressive weakness and tingling in the right lower extremity that progressed to the left lower extremity while bench pressing weights, resulting in complete lower extremity paralysis. Magnetic resonance imaging (MRI) revealed a 3.0 cm extradural mass centered in the dorsal and left lateral canal. After a T1-T4 hemilaminectomy was performed which was followed by inpatient rehabilitation, the patient had a favorable outcome improving from The American Spinal Injury Association Impairment Scale (AIS) grade A, complete impairment, to AIS grade C, incomplete impairment on discharge. Initially, the patient had complete motor and sensory paralysis below the level of T4, and upon discharge, the patient was able to attain modified independence in activities of daily living, mobility, and transfer. Due to the lack of risk factors for SSEH in this patient, the etiology is most likely related to the Valsalva maneuver while weightlifting. Lesions in the thoracic region with rapid progression of neurologic symptoms are indicators of poor prognosis, so this case highlights the importance of prompt recognition and intervention for improved outcomes to prevent devastating neurologic defects.

The Necessity of Extensive Decompression for Spinal Epidural Hematoma: A Case Report and Literature Review

Spinal epidural hematomas (SEHs)are space-occupying lesions that exert pressure on the spinal cord by rapidly accumulating blood between the dura and bone or ligament components. The annual incidence of spontaneous epidural hematoma is estimated to be one in one million. The predominant symptoms are back pain or neurological impairment, including sensory, motor, or autonomic dysfunction of the limbs below the hematoma level. Depending on the level and size of the hematoma and the affected cord, they cause neurological deficits. Neurological deficits are often reversible if diagnosed and treated early with surgical decompression. However, neurological deficits can become permanent if the patient is not operated on timely, and paraplegia or quadriplegia may occur. A 53-year-old man presented to our emergency department with acute-onset back pain and 36-hour-long, rapidly progressive paraparesis of both legs. On T1- and T2-weighted MRI scans, a hyperacute SEH was found as iso/hyperintense and hyperintense, respectively. Immediate decompressive laminectomy from T10 to L2 and hematoma evacuation were performed. It was challenging to remove the hematoma due to its firm consistency. Before performing a bilateral total laminectomy at five levels, the posterior spine was stabilized between T10 and L3 using transpedicular screws. Within 24 hours, the motor function of the lower limbs increased considerably. The patient could sit on a chair because of posterior stability. In addition to the importance of early diagnosis using imaging techniques, planning the extension of SEH surgery is crucial for the patient's postoperative neurological recovery.

A Rare Presentation of Spontaneous Spinal Epidural Hematoma as Spinal Cord Compression and Complete Paraplegia: A Case Report and Review of the Literature

Spontaneous spinal epidural hematoma (SSEH) is a serious but infrequent cause of profound neurological compromise of acute onset. It is often an atraumatic occurrence, and in around half of the cases, no etiology is identified. However, several causes such as arteriovenous malformation in the spine, use of anticoagulants in various cardiovascular diseases, and spinal trauma have been incriminated for its development. Here we encountered a case of SSEH following unregulated use of anticoagulants after a mitral valve replacement surgery. The patient had complete paraplegia with bowel and bladder involvement. The case was treated with decompressive laminectomy with regularization of her coagulation profile. Although she presented late to the healthcare center for the treatment, she showed a remarkable neurological improvement with gaining power worth near independent ambulation after one year of follow-up.

Spinal epidural hematoma after spinal manipulation therapy: Report of three cases and a literature review

BACKGROUND

Spinal manipulation therapy (SMT) has been widely used worldwide to treat musculoskeletal diseases, but it can cause serious adverse events. Spinal epidural hematoma (SEH) caused by SMT is a rare emergency that can cause neurological dysfunction. We herein report three cases of SEH after SMT.

CASE SUMMARY

The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT. Her symptoms persisted after 3 d of conservative treatment, and she was admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated an SEH, extending from C6 to C7. The second case was a 55-year-old man with sudden back pain 1 d after SMT, numbness in both lower limbs, an inability to stand or walk, and difficulty urinating. MRI revealed an SEH, extending from T1 to T3. The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT. He was unable to stand or walk and experienced mild back pain. MRI revealed an SEH, extending from T1 to T2. All three patients underwent surgery after failed conservative treatment. The three cases recovered to ASIA grade E on day 5, 1 wk, and day 10 after surgery, respectively. All patients returned to normal after 3 mo of follow-up.

CONCLUSION

SEH caused by SMT is very rare, and the condition of each patient should be evaluated in full detail before operation. SEH should be diagnosed immediately and actively treated by surgery.

Cervical epidural hematoma after spinal manipulation therapy: a case report

BACKGROUND

Cervical spinal manipulation therapy is a common non-invasive treatment for neck pain and stiffness, and has been widely used in the population. However, most people do not pay attention to the potential risks of neck manipulation, such as ligament damage, fractures, and spinal cord injuries. Epidural hematoma is a disease in which blood accumulates in the epidural space of the vertebral body. This disease is usually caused by trauma or iatrogenic surgery, and may be associated with blood coagulopathies, neoplasms, or degenerative spinal disease. Reports of epidural hematoma caused by cervical spinal manipulation are rare.

CASE PRESENTATION

We present the case of a patient with tetraplegia and spinal shock after neck manipulation. A physical examination of the patient on admission found tenderness in the neck and increased muscle tension in both upper limbs. The superficial sensation of the upper limb disappeared, but the deep sensation still remained. The lower extremity had 0/5 power on both sides. The sensation below the T2 level completely disappeared. A cervical magnetic resonance imaging scan showed an acute posterior epidural hematoma from the C3-T3 vertebrae. Ultimately, the patient underwent emergency hematoma removal and showed partial improvement in symptoms of paralysis during follow-up.

CONCLUSIONS

Although spinal manipulation is simple and neck pain is common and recurrent in the general population, the basic condition and disease history of patients should be determined before manipulation. For high-risk patients, caution should be applied for cervical spinal manipulation or it should be prohibited. For a suspected hematoma, MRI should be used at an early stage to diagnose and locate the hematoma.

Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

Background

Spinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis.

Case presentation

A 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine.

Conclusions

Partial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Spontaneous resolved cervical spine epidural hematoma: A case report

Background:

Cervical spine epidural hematomas (CSEH) are rare, and surgical intervention is typically required. Here, we present the rare case of a CSEH resulting from chiropractic manipulation successfully treated conservatively.

Case Description:

A 44-year-old female with cervical myelopathy presented with a mild quadriparesis following manipulation by a chiropractor. Although magnetic resonance (MR) documented a CSEH, the lesion was treated nonsurgically as the patient refused operative intervention. Four days later, the patient demonstrated spontaneous improvement. Furthermore, the 1-month post manipulation cervical MR showed resolution of the CSEH mass effect, and her myelopathy fully resolved.

Conclusion:

Few studies document the efficacy of conservative treatment of CSEH. In this case, a patient with cervical myelopathy presented with a mild quadriparesis following chiropractic manipulation. Although MR documented a CSEH, she refused surgery, but fortunately improved neurologically within the next 4 days and was intact within 1 postoperative month. We recommend performing more powerful studies with large sample size to better define criteria for conservative vs. surgical treatment of CSEH.

Spontaneous spinal epidural hematoma: literature review

Review the current literature regarding spontaneous spinal epidural hematomas (SSEHs) and report on the known risk factors, evaluation, and treatment of this rare entity. A literature search was performed using PubMed and Ovid to identify articles pertaining to SSEHs. Due to the rarity of the pathologic entity, only scattered case reports and associated reviews are available. SSEHs are a rare yet potentially life-altering event. The underlying risk factors are poorly understood, and SSEHs present with minimal or no antecedent trauma. SSEHs warrant urgent surgical intervention given the associated risk of permanent neurologic sequelae. Given the potential for persistent neurologic deficits, physicians must entertain a clinical suspicion of SSEH when a patient presents with a history of back pain followed by neurologic deficits. Even without clear risk factors for hemorrhage, the appropriate evaluation to include advanced imaging studies should be obtained to allow for identification of this entity and urgent surgical management.

Cerebral Hemorrhage Following Chiropractic Activator Treatment - Case Report and Review of Literature

Background Despite widespread utilization of chiropractic treatment for various ailments, there is a paucity of documentation regarding intracerebral hemorrhage related to chiropractic trauma. Stroke has been reported from cervical manipulation, although with a suggested low incidence. Activator treatment, an instrument that produces a high-velocity, low-amplitude impact to the spine, is considered especially safe. There are no prior reports of intracerebral hemorrhage resulting from a chiropractic activator treatment. Case Description A 75-year-old woman was admitted to the hospital with a history of headaches, visual difficulties on the right, and speech disturbance of relatively acute onset. CT scan showed a brain hemorrhage in an unusual location. Extensive evaluation was undertaken because this was thought to be a spontaneous event. No cause was found on imaging. Subsequent history revealed a chiropractic activator treatment applied directly to the junction of the back of her head and the upper cervical spine immediately prior to the onset of symptoms. Her clinical course is described. Conclusions This appears to be the first report linking traumatic intracerebral hemorrhage with a chiropractic activator treatment. The use of this modality in an elderly population, with widespread utilization of anticoagulants and platelet inhibitors, is of potential concern.