Complete nonsurgical resolution of a spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematomas (SSEH) are heralded by spinal pain and progressive cord compression syndromes which may lead to permanent neurological disability or death if emergent neurosurgical intervention is delayed. It therefore must be considered early in the differential diagnosis of acute spinal cord compression syndrome. A case of spontaneous spinal epidural hematoma presenting as an acute myelopathy in a clarinet player who chronically used a nonsteroidal anti-inflammatory medication is presented. The case was remarkable for the rare complete spontaneous resolution of neurological function. Approximately 250 cases of SSEH have been reported in the medical literature, although only a handful of these patients have recovered spontaneously. This is the sixth report of such an event. The etiologies, contributing factors, disease progression, and treatment recommendations are discussed.     

A rare diagnosis in emergency department: spontaneous spinal epidural hematoma

We report a case of a 32-year-old man who presented to the emergency department (ED) with a sudden onset of paraplegia due to spontaneous spinal epidural hematoma. Although the patient had a poor neurological condition on presentation, he was successfully operated and discharged without any neurological sequel. Spontaneous spinal epidural hematoma is a rarely seen clinical entity, especially in the ED. Magnetic resonance imaging is the best choice for early diagnosis, and urgent surgical decompression is essential to prevent serious neurological deficits.     

Spontaneous spinal epidural hematoma of thoracic spine: a rare case report and review of literature

Spontaneous spinal epidural hematoma is a rare condition of spinal cord compression, and emergent decompressive surgery is strictly indicated. Early recognition, accurate diagnosis, and rapid treatment may result in decreased morbidity and improved outcome. Here, we present a case of a 50-year-old man who sustained sudden onset of severe back pain, followed by progressive weakness and numbness over bilateral lower limbs. Magnetic resonance imaging of thoracic spine demonstrated an epidural mass extending from T6 through T8, causing spinal cord compression. Emergent decompressive surgery was performed, and epidural hematoma was diagnosed postoperatively; the patient had significant improvement of neurologic deficits. The relevant literature is also reviewed.     

An Unusually Rapid Spontaneous Recovery in a Patient With Spinal Epidural Hematoma

Background: Spontaneous epidural hematoma is a rare condition, which usually requires urgent surgical treatment. Objectives: To report two cases of spontaneous epidural hematoma, one of which was treated conservatively, and the other surgically, and discuss the possibility of unusual spontaneous recovery and treatment decision-making. Case Report: We encountered 2 patients with spontaneous spinal epidural hematoma, both of whom were taking an anti-platelet agent, producing severe paraplegia. One patient with a hematoma at C2–T3 experienced a rapid neurological recovery while a magnetic resonance imaging scan was being performed. A complete resolution of the hematoma and complete neurological recovery ensued without surgical intervention. A second patient with a hematoma at T10–12 showed no neurological recovery up to the time emergency surgery started and was treated surgically by T10–12 laminectomy and excision of the hematoma. Neurological function returned to normal in both patients. Conclusion: The occurrence of spontaneous recovery in some patients makes the decision for surgery difficult. Emergency physicians need to be aware of the possibility of spontaneous rapid neurological recovery in patients with spinal epidural hematoma. To avoid unnecessary surgery in patients who will spontaneously have neurological recovery, neurological evaluations need to be repeatedly performed up to the time the emergency surgery begins. However, unfortunately, there is no diagnostic tool at present to identify the patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results, therefore, conservative treatment should be prescribed only for those patients who exhibit improving neurological signs early in the clinical course.     

A Case Report: An Acute Spinal Epidural Hematoma after Acupuncture Mimicking Stroke

BackgroundSpinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately.Case ReportWe describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later.Why Should an Emergency Physician Be Aware of This?Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.     

Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing

Spontaneous spinal epidural hematoma is an uncommon clinical entity. Patients with this disease may present with devastating neurological deficits that can mimic other diseases. Emergency physicians should be familiar with this condition to assure appropriate therapy in a timely manner. A typical case of spontaneous spinal epidural hematoma is presented with review of appropriate differential diagnosis and management.     

ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home

Background

Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.

Case presentation

We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.

Conclusions

The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.     

AANA journal course. Update for nurse anesthetists. 2. Anticoagulation and spinal and epidural anesthesia

An increasing number of surgical patients preoperatively are taking anticoagulant medications. These patients are at an increased risk for development of epidural hematoma with spinal or epidural anesthesia. It is the responsibility of the anesthesia provider to understand and anticipate this risk and to alter the anesthetic plan accordingly. The purpose of this AANA Journal course is to update anesthesia providers regarding the common anticoagulants used for surgical patients, the risks associated with epidural and spinal anesthesia in conjunction with anticoagulation, and recommendations for the use of epidural and spinal anesthesia in anticoagulated patients. Antiplatelet drugs, oral anticoagulants, heparin, low-molecular-weight heparin, other new anticoagulants, and herbal medications are reviewed. When spinal or epidural anesthesia is considered for a patient who has been taking anticoagulant medications, the risk of epidural hematoma vs the benefits of regional anesthesia must be weighed carefully. Appropriate management of the patient extends well into the postoperative period and should include anesthesia providers, attending physicians, and nurses.     

急性硬脊膜外血肿的诊治

目的 研究急性硬脊膜外血肿的原因、临床表现、影像学特点及治疗方法。方法 对10a来经手术治疗的32例急性硬脊膜外血肿的病因、临床表现、MRI、DSA检查情况、手术治疗和随访结果进行分析。结果 32例病人中有26例直接手术清除血肿；6例先栓塞硬脊膜动静脉瘘（AVF）的供血动脉后，再手术清除血肿并切除瘘口。随访2－9a。神经系统恢复到正常情况11例；有轻度神经系统改变但生活可以自理15例；需他人帮助者4例；2例因血肿压迫时间，术后双下肢瘫痪及尿留渚留未改善；本组无死亡。结论 急性硬脊膜外血肿的早期诊断和治疗是提高疗效的关键。脊髓MRI检查是诊断急性硬脊膜外血肿的首选方法，清除血肿减轻其对脊髓的压迫是治疗本病的唯一有效方法、大的、高血流量的AVF术前栓塞供血动脉可减少术中出血。     

Cervical spinal epidural hematoma mimics acute ischemic stroke

Spinal epidural hematoma is an accumulation of blood in the epidural space that can mechanically compress the spinal cord. It is an uncommon condition, and most cases occur spontaneously. Detailed evaluation of neurologic deficit and detailed history taking are important tools for early diagnosis, and magnetic resonance imaging is currently the diagnostic method of choice. Prompt surgical intervention is important in achieving positive clinical outcomes. Spinal epidural hematoma usually comes with acute, severe pain with radiation to the extremities and may be accompanied with severe neurologic deficit. Common neurologic signs include paraparesis and quadriparesis. Here, we report 2 cases of cervical spinal epidural hematoma with sudden onset of neck pain, followed by the development of unilateral limbs weakness and respiratory distress. Both patients were initially suspected to have acute ischemic stroke and were considered using intravenous thrombolytic therapy with recombinant tissue plasminogen activator as treatment. Cervical spinal epidural hematoma was confirmed after obtaining magnetic resonance imaging. Patients with this uncommon presentation must be carefully distinguished from acute stroke. This article aimed to highlight the potential pitfalls in diagnosing acute hemiparesis with no cranial nerves deficits and the importance of clinical suspicion.     

Warfarin-related epidural hematoma: a case report

Spinal epidural hematomas are rare, with trauma being the most common cause. Spinal epidural hematomas caused by coagulation dysfunction are even rarer; however, long-term warfarin therapy increases the risk. The clinical manifestations of spinal epidural hematoma are neurological deficits below the corresponding spinal cord segment level. Magnetic resonance imaging (MRI) is the preferred method for diagnosis, and the main treatment for epidural hematoma with typical symptoms is urgent decompression of the lumbar spine. We describe an almost 80-year-old female patient who received long-term oral warfarin therapy for atrial fibrillation. She developed sudden onset waist pain, and 2 days later, she developed pain and weakness in both lower limbs. Computed tomography (CT) of the thoracolumbar spine showed no obvious hematoma. Eight days after admission, contrast-enhanced CT of the thoracolumbar spine showed intraspinal hematomas at T5–T8 and T12–L2 levels. We performed T3–T7 laminectomy, T5–T8 hematoma removal, and spinal dural repair. The clinical symptoms did not improve significantly, postoperatively. The low incidence of spinal epidural hematoma after anticoagulation treatment means this condition is not recognized timely, and it is misdiagnosed easily. Clinicians should consider this condition when patients treated with anticoagulants have neurological deficits below a spinal segmental plane.     

脊柱手术后并发症的MR表现及鉴别诊断

目的：探讨脊柱手术后并发症的MR表现和MR在诊断及鉴别诊断中的临床应用价值。方法：对114例行MRI检查的脊柱手术后并发症患者的影像学资料进行回顾性分析，并与临床资料进行对照。结果：脊柱手术后主要并发症：椎管狭窄33例（硬膜外血肿或脓肿所致12例，硬膜外纤维化与瘢痕形成21例）；脊柱失稳43例；感染23例（术后椎旁软组织感染7例，椎间盘炎5例，椎体及附件感染4例，硬脊膜外脓肿3例，脊髓炎2例，脊蛛网膜炎2例）；其他28例（内固定失败12例，硬膜外血肿9例，脑脊液漏7例）。结论：MRI可明确显示脊柱手术后的各种并发症，在其诊断和鉴别诊断中有独特价值。     

Spinal Epidural Abscess

Background: Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. Objectives: We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. Discussion: Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. Conclusion: Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.     

Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis

OBJECTIVE: To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization. MATERIAL AND METHODS: The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case. RESULTS: Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve. CONCLUSION: Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.     

Locoregional anesthesia and anticoagulation

Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. Risk factors include traumatic needle/catheter placement, sustained anticoagulation in an indwelling neuraxial catheter, and catheter removal during therapeutic levels of anticoagulation. Generally, a patient’s coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation should be monitored during epidural catheterization. Signs of cord compression, such as severe back pain, progression of numbness or weakness, and bowel and bladder dysfunction, warrant immediate radiographic evaluation. A delay in diagnosis and intervention of spinal hematoma may lead to irreversible cord ischemia.     

自发性脊髓硬膜外血肿的MRI诊断及鉴别诊断

目的探讨自发性脊髓硬膜外血肿的MRI表现及鉴别诊断。方法11例自发性脊髓硬膜外血肿，男7例，女4例，年龄27—74岁，平均53岁。本组病例均无明确外伤史。常规行SE T1WI、T2WI矢状位及T2WI轴位，部分患者行脂肪抑制。6例注射Gd—DTPA增强扫描。结果11例自发性脊髓硬膜外血肿中，9例位于椎管内背侧，2例位于椎管内背外侧。病变范围累及4—5个锥体节段，颈段8例，胸段3例。血肿呈长条状及长梭形。5例血肿呈T1WI、T2WI高信号，4例血肿呈T1WI、T2WI等、低、高混杂信号，2例呈T1WI及T2WI等信号。增强扫描，2例血肿壁强化，4例未见强化。结论MRI是脊髓硬膜外血肿最佳检查方法，能清楚显示血肿部位、范围，区分急慢性血肿，判定脊髓受压受损情况。     

自发性脊髓硬膜外血肿MRI诊断

目的:探讨自发性脊髓硬膜外血肿MRI表现及其鉴别诊断。材料与方法:9例自发性脊髓硬膜外血肿,男4例,女5例,年龄9~57岁,平均36岁。所有病例均无明确外伤史。常规行SE T1WI矢状位及轴位,T2WI矢状位及轴位。7例注射Gd-DTPA行增强扫描。结果:9例自发性脊髓硬膜外血肿中,位于椎管内背侧8例,仅1例位于椎管内腹侧,累及3~5个椎体节段,平均4个椎体节段。颈段4例,颈胸段4例,腰段1例。血肿呈新月形及长条状。3例血肿呈T1WI及T2WI高信号,4例血肿T1WI呈等信号,T2WI呈高信号。2例T1WI及T2WI均呈等高混杂信号。血肿与脊髓间T1WI及T2WI均可见低信号线相隔,以T2WI明显。增强扫描3例见血肿壁强化,4例未见强化。结论:MRI是自发性脊髓硬膜外血肿最佳检查方法,可清楚显示血肿部位、范围、血肿的新旧程度及脊髓受压受损情况。     

A posterior epidural mass causing paraparesis in a 20-year-old healthy individual

We present a case of a posterior epidural abscess at the thoracic vertebral level causing paraparesia in a young, healthy individual with no otherwise predisposing factors, with normal laboratory findings, as diagnosed using fat-suppressed MR imaging. Spinal epidural abscess is a rare condition, encountered mostly in the midthoracic or lower lumbar vertebral levels of elderly patients, that has a high mortality and morbidity (18-31%) when diagnosis and treatment is delayed. It is rarely spontaneous and is usually accompanied by spinal osteomyelitis. Diagnosis is rather easy in cases of vertebral osteomyelitis or when classical clinical, laboratory and imaging findings are present. However, cases of spontaneous development, with no predisposing factors, and lack of abscess suggesting clinical and laboratory findings may be a diagnostic challenge. In such cases, other posterior epidural masses such as schwannoma, neurofibroma, meningioma and hematoma should be considered in the differential diagnosis. Both the clinician and the radiology physician should have a high suspicion of epidural abscesses, because their early diagnosis and treatment is important. In addition to routine MR images, fat-suppressed MR images prove helpful in the diagnosis of spontaneous epidural abscesses by showing the inflammatory changes in the paraspinal area.     

Spontaneous spinal epidural hematoma causing cord compression after streptokinase and heparin therapy for acute coronary artery occlusion

We have reported a case of spinal epidural hematoma with cord compression in a 49-year-old man treated with short-term streptokinase and continuous heparin infusion. The sudden onset of back pain with subsequent neurologic deficits in a patient treated with fibrinolytic therapy alone or in combination with an anticoagulant should prompt an evaluation for spinal epidural hematoma with associated cord compression. The risk of combined fibrinolytic and anticoagulant therapy is not clear and warrants further evaluation.     

Acute spontaneous thoracic epidural hematoma associated with intraspinal lymphangioma: A case report

BACKGROUNDSpontaneous spinal epidural hematoma is a rare neurosurgical emergency.CASE SUMMARYA 53-year-old healthy woman suffered from complete paraplegia in both legs and loss of all sensation below the xiphoid process. She was diagnosed as acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma. The primary lab survey showed all within normal limits. Presence of a posteriorly epidural space-occupying lesion at the T4-T8 level of the spinal canal was confirmed on magnetic resonance imaging. A decompressive laminectomy was performed from the T4 to T7 levels at the sixth hour following abrupt onset of complete paraplegia. The lesion was confirmed as lymphangioma. This patient recovered well within one month.CONCLUSIONThis study reports a case of acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma with well recovery after surgical intervention.