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].

• Axillary Pain

  He was admitted with axillary pain and slowly progressive weakness after a fall that had occurred 4 wks before. On admission, he could not stand or hold a spoon. [ncbi.nlm.nih.gov]

• Splenomegaly

  Physical exam was positive for splenomegaly and subcutaneous ecchymosis. [theassr.org]

• Wheelchair Bound

  However, the patient remained substantially weak in her lower extremities and was wheelchair bound at 3 months postoperatively. [ncbi.nlm.nih.gov]

• Feeding Difficulties

  […] and weakness of the upper arms, with major difficulty in feeding himself. [em-consulte.com]

• Subcutaneous Nodule

  Angiolipomas are benign tumors usually manifested as subcutaneous nodules. Rarely they may form spinal extradural masses. These spinal cavernous angiolipomas have mostly been described in adults. [ncbi.nlm.nih.gov]

• 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 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. [symptoma.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]

• Lhermitte Sign

  In one case, the presentation was neck pain and in the other case, it was Lhermitte's sign; brain magnetic resonance imaging (MRI) and magnetic resonance angiography were negative for signs of ischemic infarction, hemorrhage, or arterial dissection. [ncbi.nlm.nih.gov]

• 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]

  He was diagnosed with prostatitis as the source of his urinary incontinence—due to concern for infection following the recent tooth extraction. [jss.amegroups.com]

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.

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]

Additionally, a lack of sensory sparing suggests a worse prognosis than an individual presenting with some degree of sensation ( 4 ). [jss.amegroups.com]

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]

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]

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

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