Isolated Retrodental Epidural Hematoma Without Dens Fracture

BackgroundTraumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being < 1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma.Case ReportA 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin.Why Should an Emergency Physician Be Aware of This?Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.     

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.     

MRI鉴别诊断椎管内结核瘤、转移性肿瘤及神经纤维瘤病

目的 分析椎管内结核瘤、转移瘤以及神经纤维瘤病的MRI表现及鉴别诊断要点。方法 回顾性分析8例椎管内结核瘤、10例椎管内转移性肿瘤、3例椎管内神经纤维瘤病患者的临床和MRI资料。所有病例经临床随访证实,均接受MR平扫,20例同时接受增强扫描。结果 椎管内结核瘤和转移瘤位于颈、胸、腰段多个节段,脊髓内外均有,主要位于髓外硬脊膜下;椎管内神经纤维瘤病主要位于腰段马尾神经周围,颈、胸段脊髓表面见少许结节病灶。3种病变均为多发结节,呈等T1等或稍长T2信号,有明显强化。部分椎管内结核瘤病灶分界欠清,与硬脊膜紧密相连、融合,邻近硬脊膜明显增厚强化、脊髓均见程度不等的片状异常信号,其中5例马尾神经可见增粗、强化。椎管内转移瘤病灶之间分界清楚,未见明显融合,8例邻近硬脊膜者可见轻-中度强化,10例脊髓可见程度不等的片状异常信号,2例可见马尾神经增粗、强化;椎管内神经纤维瘤病病灶分界清楚,邻近硬脊膜、马尾神经未见增厚和强化,脊髓未见异常信号。结论 MRI结合临床综合分析有助于诊断及鉴别诊断椎管内结核瘤与转移瘤和神经纤维瘤病。     

Paraplegia from spinal intramedullary tuberculosis: A case report

BACKGROUNDTuberculosis (TB) mostly attacks the lungs, and extrapulmonary TB involving the central nervous system is uncommon; among these cases, spinal intramedullary TB is even more rare. The clinical manifestations of spinal intramedullary TB are similar to those of intramedullary spinal cord tumors. Therefore, it is necessary to make a careful differential diagnosis of spinal intramedullary lesions to achieve the appropriate treatment and favorable prognosis. We report a rare case of a young male patient with paraplegia due to spinal intramedullary TB, which is uncommon and regrettable.CASE SUMMARYA 23-year-old male presented with fever accompanied by nausea and vomiting lasting for 2 mo and was then diagnosed with tubercular meningitis. After anti-TB treatment, his symptoms were significantly improved. However, 2 mo after the diagnosis of tubercular meningitis, the patient felt numbness below the costal arch level, which lasted for 1 wk, and he paid no attention to this symptom. What followed was paraplegia and urine/fecal incontinence. Magnetic resonance imaging of the thoracic spine showed a ring-enhanced intramedullary cord lesion at T8-T9. Lesion exploration showed enlargement of the spinal cord at T8-T9, and the lesion could be observed by incision. The lesion was adhered to the peripheral tissue and was grayish-white and tough with a poor blood supply and a diameter of approximately 0.8 cm. The lesion was resected completely. The results of pathological examination by both hematoxylin-eosin staining and acid-fast bacilli staining confirmed TB, accompanied by acute and chronic suppurative inflammation and granulation tissue formation. The patient was instructed to continue anti-TB treatment after the operation, but he did not follow the medical advice. Follow-up continued for ten years, the patient had persistent paraplegia, the numbness disappeared and urine/fecal sensation recovered.CONCLUSIONAlthough TB is a kind of benign disease, some cases progress rapidly. Moreover, spinal intramedullary TB may seriously endanger quality of life and still needs timely diagnosis and proper treatment.     

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.     

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.     

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.     

硬膜外脊膜瘤的影像学表现

目的 观察扁平形硬膜外脊膜瘤的影像学表现。方法 回顾性分析8例经手术病理证实的扁平形硬膜外脊膜瘤的影像学表现表现,并进行文献复习。结果 7例硬膜外脊膜瘤位于颈椎管,1例位于胸椎管,累及2~4个椎体节段;8例病灶均呈扁平形、以增厚的硬膜为基底,伴硬膜外肿块形成;5例肿瘤经椎间孔向硬膜外延伸、相应水平椎间孔扩大;椎管均均匀变窄,1例伴脊髓水肿,1例伴脊髓变性。CT显示病灶呈等密度,6例硬膜可见条片状钙化。MRI显示病灶于轴位图像上均呈半环形,包绕脊髓,T1WI上呈等（n=5）或低（n=3）信号,T2WI上呈等（n=3）或低信号（n=5）;增强后呈中等（n=2）或明显（n=6）强化,其中7例强化均匀,1例不均匀。结论 扁平形硬膜外脊膜瘤好发于颈椎管,可累及多个椎体节段,以硬膜增厚、钙化并硬膜外肿块形成为其特征。     

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。     

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.     

肥厚性硬脊膜炎的MRI表现

目的 观察肥厚性硬脊膜炎(HSP)的MRI表现。方法 回顾性分析12例HSP患者的影像资料,其中7例经临床及影像学检查确诊,5例经病理证实。结果 12例HSP患者中,MR显示11例位于颈胸椎的硬脊膜增厚范围为10个以上椎体水平,1例位于胸腰椎的硬脊膜增厚累及范围为5个椎体水平;6例表现为背侧、2例为腹侧硬膜增厚,4例背侧及腹侧硬膜均增厚。2例增厚的硬膜呈结节样,1例合并硬膜外肿物形成,5例合并硬膜囊背侧脂肪增多。增厚的硬膜T2WI均呈低信号,4例T1WI呈等信号,8例T1WI呈低信号。10例增强扫描患者中,4例明显强化,1例中等强化,5例未见强化。结论 HSP以颈胸椎背侧或腹侧硬膜广泛增厚为特点,部分合并硬膜外脂肪增多;增厚的硬膜呈结节样或条带状,少数可合并硬膜外肿物形成;T2WI呈特征性低信号。     

Spontaneous Spinal Epidural Hematoma: A Case Report and Literature Review

Background: Spontaneous spinal epidural hematoma (SSEH) is a rare cause of spinal cord compression that requires emergency investigation and treatment. Prompt diagnosis is essential to prevent morbidity and mortality. Objectives: Our goal was to report a case of SSEH, and to review the literature on the topic, looking particularly at the factors influencing post-operative outcome, and the symptoms and signs that would lead one to consider this rare diagnosis. Case Report: A 36-year-old man presented to the Emergency Department with paraplegia and a sensory level at T4. There was no history of trauma and he was not taking any medications. Magnetic resonance imaging revealed a large non-enhancing posterior epidural mass lesion between C7 and upper T4, causing severe cord compression at T1–T3. Post contrast scans revealed no rim enhancement. Blood investigations were unremarkable, with an international normalized ratio of 1.1. He underwent urgent decompression laminectomy within 12 h of symptom onset. Intraoperatively, thick clotted blood and prominent epidural vessels were seen. Histology revealed engorged vessels with hemorrhage and clot in the extravascular tissues. Post-operatively, the impaired neurological status remained unchanged. Conclusion: SSEH is a rare cause of spinal cord compression that requires prompt diagnosis and surgical intervention to prevent morbidity. Neurological outcome after surgical decompression depends on the severity of preoperative neurological deficits as well as the time between symptom onset and surgery.     

急性自发椎管内血肿临床诊治及预后分析

目的：探讨急性自发性椎管内血肿的临床特点、治疗及预后因素。方法回顾性分析浙江大学医学院附属第二医院自2011年1月至2014年3月收治的38例自发性椎管内血肿患者临床资料,对流行病学、临床特征、以及治疗和预后进行评估。结果38例患者中,硬膜外血肿29例,硬膜下5例,蛛网膜下腔1例,髓内血肿3例。男性22例,女性17例;血肿分布以颈、胸段最多。29例患者行手术治疗,9例患者保守治疗。脊髓损伤ASIA A和B级的患者出院后6个月随访JOA评分恢复率为（51.26±38.97）％, ASIA C、 D、 E级的患者恢复率为（80.33±25.83）％（P＜0.05）;24 h内手术减压的患者神经功能恢复率明显优于24 h后手术患者（P＜0.05）。结论诊断急性椎管内血肿MRI是首选检查。对于已明确出血节段、症状较重且呈现进展趋势的患者应尽快急诊手术。预后与术前神经功能状态和术前病程时间有密切相关。     

12例急性脊髓刀扎伤的MRI表现

目的 研究急性脊髓刀扎伤的磁共振成像（MRI）特征。方法 对12例急性脊髓刀扎伤患者的MRI进行回顾性分析。结果 12例均可见入路信号,椎管外一椎管内的刀迹金属伪迹影;此外,亦可见脊髓内的刀迹金属伪迹影、脊髓损伤信号、水肿信号、脊髓出血信号、硬膜外、下血肿出血信号。硬膜下、外血肿的鉴别可通过硬膜在血肿与脊髓间的关系来鉴别;矢状T1、T2加权相可以清晰地显示黄韧带、后纵带及硬膜的损伤或断裂。结论 MRI可准确诊断脊髓刀扎伤的部位,髓内、髓外及韧带、硬膜的损伤,尤其是矢状T2W相可清晰、准确地显示刀扎入的路径。     

椎管内节细胞神经瘤MRI征象

目的 分析椎管内节细胞神经瘤的MRI征象,以提高术前诊断能力。方法 回顾性分析9例经手术病理证实、累及椎管的节细胞神经瘤MRI资料,观察肿瘤位置、形态、大小、信号和强化程度等。结果 共纳入9个病灶,其中位于颈椎4个,胸椎2个,腰骶椎3个;7个累及椎管内外,呈哑铃状,2个位于椎间孔区,呈结节状;9个病灶T2WI均呈均匀或不均匀高信号,1个病灶内见囊变坏死。8个接受增强扫描的病灶中,3个呈明显强化,5个呈轻中度强化,4个病灶内见条状强化。所有病灶均伴有受累椎间孔扩大,但骨质未见破坏。结论 椎管内节细胞神经瘤MRI表现具有一定特征性,有助于术前准确诊断。     

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。     

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.     

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 case of paraplegia complicating a lumbar epidural infiltration

ObjectiveWe report the case of a patient who developed paraplegia following a low lumbar epidural steroid injection. Alternative approaches to (or alternative means of) performing transforaminal injections should be considered, in order to avoid devastating neurological complications.Case reportA 54-year-old man (who had undergone surgery 14 years earlier to cure an L5-S1 slipped disc with right S1 radiculopathy) presented with low back pain (which had begun 6 weeks previously) and left S1 radiculopathy. During a second infiltration of prednisolone acetate, the patient reported feeling a heat sensation in his legs and concomitantly developed facial flushing. Immediately after the injection, the patient developed complete, flaccid T7 ASIA A motor and sensory paraplegia. Three days later, T2 magnetic resonance imaging (MRI) of the spine revealed a spontaneous hypersignal in the conus medullaris and from T6 to T9, suggesting medullary ischemia. Recovery has been slow; after 4 months of treatment in a physical and rehabilitation medicine department, urinary and sensory disorders are still present (T7 ASIA D paraplegia). The patient can walk 200 m unaided. Three months later, the MRI data had not changed.DiscussionThis is a rare case report of paraplegia following low lumbar epidural infiltration via an interlaminar route. The mechanism is not clear. Most of authors suggest that the pathophysiological basis of this type of complication is ischemia caused by accidental interruption of the medullary blood supply. Direct damage to a medullary artery, arterial spasm or corticosteroid-induced occlusion due to undetected intra-arterial injection could result in medullary infarction. This serious incident should prompt us to consider how to avoid further problems in the future. It also raises the issue of providing patients with information on the risks inherent in this type of procedure.ConclusionDespite the rarity of this complication, patients should be made aware of its potential occurrence. In the case reported here, the functional prognosis is uncertain.     

Endovascular coil embolization of a spinal epidural arteriovenous fistula with associated cord compression from an enlarging venous varix

Spinal arteriovenous fistulas (AVFs) completely isolated to the epidural compartment are exceedingly rare. As such, the optimal management of these lesions is poorly defined. The aim of this technical note is to describe our endovascular technique for the occlusion of a purely epidural AVF of the thoracic spine associated with cord compression from an associated enlarging venous varix. A 40-year-old male presented with severe right-sided back pain and anterior thigh numbness after a sports-related back injury six months previously. Spinal magnetic resonance imaging (MRI) showed an enhancing, extradural mass lesion at T12. Spinal angiography revealed an epidural AVF supplied by a radicular branch of the right T12 subcostal artery and draining into the paravertebral lumbar veins, as well as an adjacent 20 × 13 mm² contrast-filling sac, compatible with a dilated venous varix. There was no evidence of intradural venous drainage. We elected to proceed with endovascular treatment of the lesion. At the time of embolization five days later, the venous varix had enlarged to 26 × 16 mm². The T12 epidural AVF was completely occluded with two coils, without residual or recurrent AVF on follow-up angiography one month later. The patient made a full recovery, and complete resolution of the venous varix and cord compression were noted on MRI at three months follow-up. Endovascular coil embolization can be successfully employed for the treatment of appropriately selected spinal epidural AVFs. Cord compression from an enlarging venous varix can be treated concurrently with endovascular occlusion of an associated spinal epidural AVF.