Spinal epidural hematoma (SEH) is an uncommon condition usually characterized by acute back pain. This is followed by the onset of progressive neurological symptoms. The causes of SEH range from iatrogenic to idiopathic.
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].
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.