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Spinal Epidural Hematoma

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.


Presentation

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]
Wheelchair Bound
  • However, the patient remained substantially weak in her lower extremities and was wheelchair bound at 3 months postoperatively.[ncbi.nlm.nih.gov]
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
  • A common problem encountered by interventional cardiologists is back pain in patients who have undergone interventions in the femoral region and have lain in the same position for an extended period.[ncbi.nlm.nih.gov]
  • 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]
  • Spinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain.[ncbi.nlm.nih.gov]
  • 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.[symptoma.com]
  • General physicians should consider the possibility of SSEH when they encounter a patient with a sudden onset of unexplained cervical or back pain or subsequent radicular symptoms during anticoagulant therapy.[ncbi.nlm.nih.gov]
Shoulder Pain
  • She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis.[ncbi.nlm.nih.gov]
Hyperreflexia
  • At the neurological examination, he was found to have tetra-hyposthenia with tetra-hyperreflexia.[em-consulte.com]
  • On admission, she exhibited low-grade fever (oral 37.5 C) and severe cervical paraspinal muscle spasm accompanied by 4/5 quadriparesis (based on muscle strength grading 0–5), left upper limb hyperreflexia, and a left positive Hoffmann's sign.[surgicalneurologyint.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]
Lhermitte's 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]
Monoplegia
  • A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity.[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]
  • 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]
Uremia
  • Patients who undergo hemodialysis (HD) are at risk of bleeding due to anticoagulation during dialysis and uremia. However, SSEH in HD patients undergoing HD has rarely been reported.[ncbi.nlm.nih.gov]
  • Hemodialysis patients are at an increased risk of bleeding due to the platelet dysfunction caused by uremia and the use of anticoagulants during dialysis. Spontaneous spinal hematoma is a rare disorder as a complication in hemodialysis patients.[ncbi.nlm.nih.gov]

Workup

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.

Treatment

  • 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]
  • The rapid improvement of the patient's neurologic symptoms justified the adoption of a conservative treatment strategy. This gave excellent long-term results.[ncbi.nlm.nih.gov]
  • Traumatic spinal epidural hematoma (TSEH) is a rare neurosurgical condition that according to conventional treatment requires prompt surgical decompression.[ncbi.nlm.nih.gov]
  • Surgical treatment may be considered if medical treatment fails. A 26-year-old man presented with lower back pain and significant radicular symptoms on the left side for a week. He denied previous lumbar trauma or the use of anticoagulation drugs.[ncbi.nlm.nih.gov]
  • Postoperative compressive spinal epidural hematoma (SEH) is a devastating complication and early diagnosis and treatment is essential. The most commonly accepted treatment is decompression and drainage of hematoma.[ncbi.nlm.nih.gov]

Prognosis

  • Although several factors have been associated with prognosis, controversy remains, partly due to its rarity.[ncbi.nlm.nih.gov]
  • Because of bleeding tendencies in these cases the spinal cord was not pressed by the hematoma; this contributed conclusively to the prognosis.[ncbi.nlm.nih.gov]
  • The authors suggest that the postoperative SEH in the Type II will be treated with NPWT, and the new classification will be helpful for prognosis, diagnosis, and management of the recurrent SEHs.[ncbi.nlm.nih.gov]
  • Additionally, a lack of sensory sparing suggests a worse prognosis than an individual presenting with some degree of sensation ( 4 ).[jss.amegroups.com]
  • The most important factor for prognosis and litigation outcomes is to diagnosis and treat the patient within 48 hours.[healio.com]

Etiology

  • 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 (SSEH) is a rare condition, and its etiology remains unclear.[ncbi.nlm.nih.gov]
  • Therefore, we proposed a classification of SEH, according to the most probable etiology whatever the associated factors, in six groups: spontaneous, secondary, iatrogenic, traumatic, recurrent, and idiopathic SEH.[ncbi.nlm.nih.gov]
  • Possible mechanisms and etiological relation to patient's risk factors as well as diagnosis and management of SEH are briefly discussed. Asklepieion General Hospital of Voula, Athens, Greece.[ncbi.nlm.nih.gov]
  • This study assesses the etiology, clinical management, and outcome of patients with spontaneous spinal epidural hematoma (SSEH). SSEH is an uncommon neurosurgical emergency.[ncbi.nlm.nih.gov]

Epidemiology

  • ; 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]
  • Discussion Etiology, epidemiology and pathophysiology Despite the fact that SSEH accounts for 13 with an estimated annual incidence of only 1 per million, 15 the exceedingly high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis[nature.com]
  • Estimated figures in epidemiological studies are presented as confidence intervals: the lowest and the highest probabilities that would include 95% of cases.[allaboutepidural.com]
Sex distribution
Age distribution

Pathophysiology

  • Spinal venous wall instability due to intravenous pressure changes and the resultant venous rupture seem to be the underlying pathophysiological mechanisms.[ncbi.nlm.nih.gov]
  • 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.[journals.lww.com]
  • The pathophysiology for spinal epidural hematoma is unclear; however, it is commonly described as internal rupture of the Batson vertebral venous plexus. 6 This disease can occur spontaneously or with minor trauma, such as lumbar puncture or epidural[healio.com]
  • Porth Pathophysiology: Concepts of Altered Health States . Lippincott Williams & Wilkins. p. 1256. ISBN 9781605477817 . a b c Pryse-Phillips, William (6 May 2009). Companion to Clinical Neurology . Oxford University Press. p. 335.[en.wikipedia.org]
  • Discussion Etiology, epidemiology and pathophysiology Despite the fact that SSEH accounts for 13 with an estimated annual incidence of only 1 per million, 15 the exceedingly high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis[nature.com]

Prevention

  • Therefore, postoperative spinal epidural hematoma would not be prevented by LD.[ncbi.nlm.nih.gov]
  • Urgent decompression is required to prevent neurological sequelae. The pregnancy may either be continued or delivered depending on the gestational age and severity of the disorder.[ncbi.nlm.nih.gov]
  • Early diagnosis and urgent surgical management are needed to prevent permanent neurologic deficits. We report a case of a 30-year-old patient who presented with Brown-Séquard syndrome due to spontaneous SEH.[ncbi.nlm.nih.gov]
  • A 57-year-old man who had hypertension and had been on dual antiplatelet therapy with aspirin and clopidogrel for primary prevention presented with the sudden onset of mid back pain and monoplegia of the left lower extremity.[ncbi.nlm.nih.gov]
  • We also aim to reinforce the notion of keeping a high degree of clinical suspicion to identify and intervene at the earliest stage to prevent the physically and socially challenging consequences of SSEH.[ncbi.nlm.nih.gov]

References

Article

  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.

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Last updated: 2018-06-21 22:18