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

  The patient referred a recent and abrupt worsening of the neck pain, with increasing walking and feeding difficulties. At the neurological examination, he was found to have tetra-hyposthenia with tetra-hyperreflexia. [em-consulte.com]

• Jaundice

  A 76-year-old woman on warfarin for a past pulmonary embolism presented to the emergency room with jaundice, myalgia, hematuria, neck pain, and an International Normalized Ratio (INR) of 14. [ncbi.nlm.nih.gov]

• Miosis

  No neurological abnormalities were found except for a miosis of the right pupil due to a suspected Horner syndrome. Magnetic resonance imaging of the spine showed an extensive epidural hematoma. [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

  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 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]

• Mid Back Pain

  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]

  Ortho, 33; NS, 33 Other consultation, % a 50 33 Table 2 Complete List of Reviewed Cases Paitient Sex/Age, y Initial Presentation a Initial Setting Region Postop b Time to Rectal Exam c Specialty Outcome Complaint Verdict ( ) Surgery Consult Imaging M/# Mid-back [healio.com]

• 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]

• Unable to Walk

  The pain rapidly progressed within a few hours, making her unable to walk. She also reported mild weakness and reduced sensation in her left lower limbs. [nature.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]

• Hyperreflexia

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

• 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]

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.

• Nephrolithiasis

  Initial differential diagnoses included nephrolithiasis, abdominal aortic aneurysm, diverticulitis, and compression fracture of the spine. Urinalysis showed moderate leukocytes, trace protein, and trace blood. [consultant360.com]

• Atelectasis

  This early ambulation improved his lung atelectasis; however, it could also be a determining cause of SEH. [jtraumainj.org]

• Hypercholesterolemia

  Case series Patient 1 A 92-year-old female with a history of hypertension, angina, hypothyroidism and hypercholesterolemia presented with sudden interscapular pain followed by increasing weakness in her upper limbs that was more pronounced on her right [nature.com]

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