Spinal epidural hematoma (SEH) is a rare emergency that transpires as a complication of several disorders, including trauma, diabetes, arteriovenous malformations, coagulopathies, and malignancy. Iatrogenic causes have been outlined, namely surgical procedures, lumbar puncture and chronic anticoagulant therapy [1]. In 40% of cases, the ailment occurs spontaneously [2] [3]. The spontaneous form mainly occurs in middle-aged individuals, while SEHs are almost never seen in children [4]. Their occurrence is only slightly more frequent in males [2]. SEHs often form in the cervical, thoracic or lumbar spine. It is unclear where the bleeding originates, but literature proposes that it may be from the epidural venous plexus or the spinal epidural arteries [2].

Symptoms include acute onset of sharp back pain or neck pain and radicular pain. Pain is worsened by coughing, sneezing or percussion over the area. Spinal shock, which may become lethal, is possible if the SEH occurs high in the cervical spine [5]. Children may become irritable, and experience bladder symptoms [4]. In post-operative patients, new onset neurological decline should prompt the suspicion of SEH. Conversely, small postoperative SEH are clinically benign [6].

The diagnosis of SEH can be challenging as neurological symptoms manifest up to days after the disease begins. The level of the spine that the hematoma occurs at, as well as the presence of cord compression and the nerve roots affected, all determine the specific neurological deficits that precipitate, and these encompass both motor and sensory dysfunction [7]. As the condition progresses, signs of paraplegia begin to develop. Patients may also complain of weakness, paresthesia, and exhibit the findings of cauda equina syndrome [8].

• Pain

  There is no consensus to stop aspirin therapy before interventional chronic pain procedures. A 73-year-old woman with postlaminectomy pain syndrome and lumbar radiculopathy underwent percutaneous spinal cord stimulator lead placement. [ncbi.nlm.nih.gov]

• Asymptomatic

  Seite 489 - Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. ‎ Seite 245 - III. Tears of the anterior cruciate ligament and menisci of the knee: MR imaging evaluation. [books.google.de]

  […] reported 58% of their patients developed asymptomatic hematoma. [ecios.org]

  Furthermore, the incidence of asymptomatic cases has been reported to be 33% to 100%. 6, 7, 8, 9, 10, 11) Determining the incidence of POSEH is problematic due to the marked variability in symptom severity. [synapse.koreamed.org]

  Studies that reported asymptomatic haematoma, diagnosed by radiological imaging; needle-based anaesthetic procedures; or spontaneous epidural haematomas (not after surgery) were excluded. [crd.york.ac.uk]

  In rare cases, small hematomas may be asymptomatic. [7] If not treated promptly, epidural hematomas can cause tonsillar herniation, resulting in respiratory arrest. [en.wikipedia.org]

• Hodgkin Lymphoma

  Cervical spontaneous epidural hematoma as a complication of non- Hodgkin's lymphoma. Eur Spine J. 1996;5(4):268–71. Hayem G, Deutsch E, Roux S, Palazzo E, Grossin M, Meyer O. [ijoro.org]

  Histologically, primary spinal epidural lymphoma is commonly of Non-Hodgkin's type than Hodgkin's type. [49] Metastases Spine is the most common osseous site for metastases [50] and third most common after lung and liver metastases. [ijri.org]

• Hemophilia A

  We describe a 13-month-old boy with hemophilia A who was admitted to the hospital because of irritability and unspecified pain for the past two days. There was no history of evident trauma, no fever. [ncbi.nlm.nih.gov]

  Hemophilia A in a senior patient: a case report of spinal epidural hematoma as first presentation. Asian Spine J. 2015;9:452-5. [ijoro.org]

  Spontaneous Spinal Epidural Hematoma in a Child with Hemophilia B × Export citation Request permission Copyright COPYRIGHT: © The Canadian Journal of Neurological 2007 References Hide All 1. Silverstein, A. Intracranial bleeding in hemophilia. [cambridge.org]

• Back Pain

  The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. [ncbi.nlm.nih.gov]

  Symptoms and Signs Symptoms of a spinal subdural or epidural hematoma begin with local or radicular back pain and percussion tenderness; they are often severe. [msdmanuals.com]

• Leg Pain

  Whereas severe paralysis was observed within 24 hours in most patients undergoing cervical and/or thoracic surgery, half of the patients undergoing lumbar surgery had symptoms of SEH such as leg pain or bladder dysfunction after suction drain removal. [unboundmedicine.com]

  None of the three patients complained of leg pain prior to MRI. We wondered whether their leg pain was influenced by the physician's suggestion. The degree of pain would have been considered nonspecific if an MRI had not been performed. [synapse.koreamed.org]

  In the postoperative anesthesia care unit, she not only continued to have severe low back and left leg pain, but newly demonstrated increased an acute left-sided foot drop. [surgicalneurologyint.com]

  There was no sign for neural compression such as numbness, weakness, bowel and bladder dysfunction, severe radicular leg pain. [jmisst.org]

  This 70-year-old woman was admitted to our institution on November 18, 1996, with a chief complaint of pain in both legs. Approximately half and one year before admission, she experienced a brutal right leg pain as she was walking. [em-consulte.com]

• Suggestibility

  Furthermore, immediate MR imaging suggested severely impaired blood flow in the left IJV. The hematoma soon resolved after spontaneous IJV thrombolysis. [ncbi.nlm.nih.gov]

• Paresis

  Hematoma is suspected in patients with symptoms and signs of acute, nontraumatic spinal cord compression or sudden, unexplained lower extremity paresis, particularly if a possible cause (eg, trauma, bleeding diathesis) is present. [msdmanuals.com]

  Clinical presentation was characterized by sudden and intense back pain that rapidly evolved into plegia of the right leg and severe paresis of the left leg. Hypoesthesia below T6 and urinary retention were also present. [ncbi.nlm.nih.gov]

  One was the operative case of a 71-year-old man who presented with left leg paresis. [academicjournals.org]

  Neurological examination revealed bilateral quadriceps paresis grade IV and right tibial anterior paresis grade III, hypoesthesia in the right L5 dermatome, normal tendinous reflexes and Lasègue's sign at 20° in the right lower limb. [scielo.br]

• Neurologic Manifestation

  Neurological manifestations during vertebroplasty, postoperative magnetic resonance imaging and computed tomography. [ncbi.nlm.nih.gov]

  Neurology 2004;63:1980-1. [ PUBMED ] [Figure 1], [Figure 2], [Figure 3] This article has been cited by 1 Neurological Manifestations of Dengue Infection Frontiers in Cellular and Infection Microbiology. 2017; 7 [Pubmed] | [DOI] 2 Longitudinal extensive [neurologyindia.com]

  If the epidural infusion is the cause of the neurologic manifestation, a return of sensory and motor function will be noted. [nysora.com]

  Also, new or progressive neurological manifestations includes muscular or ligamentous injury related to needle placement, postoperative surgical neuropraxia, prolonged or exaggerated neuroaxial block, anterior spinal artery syndrome, and pre-existing [intechopen.com]

• Hyperreflexia

  At the neurological examination, he was found to have tetra-hyposthenia with tetra-hyperreflexia. [em-consulte.com]

• Spastic Paraplegia

  Neurological examination revealed bilateral sensory disturbance of all modalities below the level of fourth dorsal vertebrae level and spastic paraplegia. Routine investigations and coagulation profile were normal. [ruralneuropractice.com]

• Clonus

  Deep tendon reflexes decreased in the left extremities, without evidence of sustained clonus, and the Babinski sign was positive in the left foot. The patient was treated by enoxaparin and aspirin due to initial suspicion of stroke with hemiparesis. [asianjns.org]

• Urinary Retention

  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. [ncbi.nlm.nih.gov]

  A previously healthy 14-year-old boy was admitted with a 15-day history of back pain, urinary retention, and weakness of both lower limbs. [ruralneuropractice.com]

  Urinary retention, which increases the risk of epidural anesthesia for pain relief. Virtsan pidättyminen, mikä lisää epiduraalisen anestesian riskiä kivunlievitykseen. [tr-ex.me]

• Urinary Incontinence

  In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11-L2. [ncbi.nlm.nih.gov]

  Other significant symptoms may include numbness, fecal incontinence, weakness, and urinary incontinence. 3) SSEH starts with a sudden pain in the neck or back. [thrombocyte.com]

  After admission to the neurology ward and initiation of anticoagulant therapy, she progressed a severe neck pain irradiating in both shoulders, particularly to the left side, urinary incontinence, and quadriparesis. [asianjns.org]

An early diagnosis of spinal epidural hematoma is important as these lesions can be reversed, if treatment is initiated in the initial stage. Magnetic resonance imaging (MRI) is the imaging modality of choice [9] [10]. MRI is able to depict well-demarcated lesions in the epidural space and will show the extension and exact location of the same [11]. It is important to capture images of the whole spine as it is not possible to predict the full extension of SEH. MRI may be performed with or without contrast. T1 and T2-weighted MRI may also be useful, and these generally show an isointense lesion within the first hours of SEH, which then changes to hyperintense lesions beyond 24 hours [11]. Computerized tomography (CT) scanning can be used as a diagnostic study if MRI cannot be obtained. CT myelography may also be requested, the SEH appearing as a hyperdense region, compared to the surrounding tissue.

Further biochemical tests may be performed, in order to detect the underlying etiology of the SEH. These may include coagulation studies, full blood count, urea and electrolytes and blood typing and crossmatching.

• Synovial Cyst

  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. [springerplus.springeropen.com]

  cysts Synovial cyst represents protrusion of synovial membrane from degenerated facet joints into the spinal canal [14] contrary to the ganglion pseudocyst, which represents a cyst that is devoid of synovial lining. [ijri.org]

Its cause and treatment strategy remain controversial. This study aimed to evaluate a significant cause of SSEH and to discuss the treatment strategy according to the clinical outcomes of patients in 2 institutions. [ncbi.nlm.nih.gov]

Although several factors have been associated with prognosis, controversy remains, partly due to its rarity. [ncbi.nlm.nih.gov]

MRI appearances, including hematoma intensity, combined with simultaneous clinical information might be very important for surgical decision making and predicting prognosis in cases of spinal epidural hematomas. [academicjournals.org]

This, to our knowledge, represents the first case reported in the literature where a primary cholestatic disease is the underlying etiology. [ncbi.nlm.nih.gov]

Spontaneous spinal epidural hematoma: a study of 55 cases focused on the etiology and treatment strategy. World Neurosurg. 2017;98:546-54. 19. Mohammed N, Shahid M, Haque M, et al. [westjem.com]

Etiology spontaneous (most common 4 ) especially in the context of a bleeding disorder or over-anticoagulation trauma, e.g. vertebral fracture iatrogenic, e.g. lumbar puncture, epidural anesthesia spinal arteriovenous malformations or other vascular anomalies [radiopaedia.org]

The epidemiology, clinical history, and radiologic findings of chronic SEH (CSEH) are not well understood, although the detection rate has increased with the widespread use of magnetic resonance imaging. [ncbi.nlm.nih.gov]

Humans; Iatrogenic Disease /prevention & Incidence; Neurosurgical Procedures /adverse effects; Postoperative Care /adverse effects; Postoperative Complications /chemically induced /epidemiology; Risk Assessment; Spine /pathology /surgery; Thromboembolism [crd.york.ac.uk]

Epidemiology Overall incidence approximately 1 per 1,000,000 people annually ( Perron 2013 ) The source of bleeding is usually venous ( Aminoff 2016 ) Traumatic spinal epidural hematoma Frequency unclear Typically will have concomitant spine fracture [coreem.net]

Epidemiology Frequency Epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year). Spinal epidural hematoma affects 1 per 1,000,000 people annually. [emedicine.medscape.com]

The pathophysiology often remains unclear. However, epidural hematoma in the lumbar spine is best described as the result of internal rupture of the Batson vertebral venous plexus. [ncbi.nlm.nih.gov]

Pathophysiology [ edit ] The anatomy of the epidural space is such that spinal epidural hematoma has a different presentation from intracranial epidural hematoma. [en.wikipedia.org]

Therefore, postoperative spinal epidural hematoma would not be prevented by LD. [ncbi.nlm.nih.gov]

Therefore, small suction drains are sufficient to prevent hematoma accumulation. However, our results do not indicate why suctions drains frequently cannot prevent POSEH. [synapse.koreamed.org]

1. Cho YW, Moon JG. Acute nontraumatic spinal epidural hematoma at cervical spine. J Korean Neurosurg Soc. 2003;34:268–270.
2. Liu Z, Jiao Q, Xu J, Wang X, Li S, You C. Spontaneous spinal epidural hematoma:analysis of 23 cases. Surg Neurol. 2008;69(3):253–260. discussion 260.
3. Baek BS, Hur JW, Kwon KY, Lee HK. Spontaneous spinal epidural hematoma. J Korean Neurosurg Soc. 2008;44(1):40–42.
4. Poonai N, Rieder MJ, Ranger A. Spontaneous spinal epidural hematoma in an 11-month-old girl. Pediatr Neurosurg. 2007;43(2):121–124.
5. Chan DT, Boet R, Poon WS, Yap F, Chan YL. Spinal shock in spontaneous cervical spinal epidural haematoma. Acta Neurochir (Wien). 2004;146(10):1161–2;discussion 1162-3.
6. Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila Pa 1976). 2002;27(15):1670-1673.
7. Yu HP, Fan SW, Yang HL, Tang TS, Zhou F, Zhao X. Early diagnosis and treatment of acute or subacute spinal epidural hematoma. Chin Med J (Engl). 2007;120(15):1303–1308.
8. Myers M, Meyers L, Fink WA. Extensive Subarachnoid and Epidural Hematoma After Lumbar Puncture. Am J Emerg Med. 2015;33(4):603.e3-4.
9. Matsumura A, Namikawa T, Hashimoto R, et al. Clinical management for spontaneous spinal epidural hematoma: diagnosis and treatment. Spine J. 2008;8(3):534–537.
10. Song KJ, Lee KB. The poor outcome of the delayed diagnosis of acute spontaneous spinal epidural hematoma: two cases report. J Korean Med Sci. 2005;20(2):331–334.
11. Fujiwara H, Oki K, Momoshima S, Kuribayashi S. PROPELLER diffusion-weighted magnetic resonance imaging of acute spinal epidural hematoma. Acta Radiol. 2005;46(5):539–542.