慢性自发性腰椎管内硬膜外血肿1例

正患者,男,77岁,因"腰痛伴双下肢麻木、疼痛、无力8年,加重2个月"于2016年11月7日入院。患者8年前腰痛,伴双下肢麻木、无力,间歇性跛行,2个月前无明显诱因出现腰痛明显加重伴双侧臀部疼痛,站立行走时疼痛明显,并伴尿频、尿急。查体:腰背部压痛、叩痛明显,伴双侧臀部放射痛,腰椎屈伸活动受限明显,右小腿及足部针刺觉减弱,双侧胫前肌肌力Ⅳ级,双拇趾背伸肌力Ⅲ级,双足跖屈肌力     

Puerperal ventral epidural hematoma after epidural labor analgesia

Serious complications in obstetric anesthesia are a rare occurrence. High neuraxial block, respiratory arrest in labor and delivery, and an unrecognized spinal catheter are among the most frequently reported serious complications. A serious complication occurs in approximately 1:3 000 obstetric patients. Neuraxial hematoma after obstetric epidural analgesia or anesthesia is extremely rare.We present a case of a puerperal spinal epidural hematoma following epidural labor analgesia. The patient presented with foot drop, which resolved after conservative treatment. We reviewed the epidemiology, clinical manifestations and treatment options for this rare complication.     

Spinal epidural hematoma following epidural catheter removal during antiplatelet therapy with cilostazol

A 90-year-old man underwent emergency thrombectomy for acute occlusion of the right femoral and popliteal arteries. After an epidural catheter (used for intraoperative/postoperative management) was removed, a spinal epidural hematoma involving the Th12 to L3 areas developed. Emergency removal of the hematoma and decompression of the spinal cord were performed. Possibly, the hematoma had developed due to therapy with an antiplatelet agent, cilostazol, which had been started on the first postoperative day, and due to the removal of the catheter, on the third postoperative day, in addition to the patient's advanced age. This case may be the first report of spinal epidural hematoma associated with both cilostazol and epidural anesthesia. From the time course in this patient, important knowledge of drug actions and follow-up may be gained for determining the timing of catheter removal in a patient receiving antiplatelet therapy with cilostazol.     

Recurrent idiopathic epidural hematoma: a case report

Spinal epidural hematoma is a relatively rare condition in children. We report the case of a 6-year-old girl who presented to a regional hospital with the complaints of severe thoracic back pain, neck stiffness, and gait disturbance of sudden onset. Clinical examination revealed no obvious cause for the symptoms. Spinal magnetic resonance imaging (MRI) revealed the presence of an epidural mass lesion extending from T1 to T3, compressing the spinal cord; the findings suggested a diagnosis of idiopathic spinal epidural hematoma. Twelve days after admission, the patient was transferred to our hospital for further observation. Blood tests, including a coagulation profile, were normal. At 22 days after the initial presentation, repeat MRI revealed resolution of the hematoma, with the mass showing an appreciable decrease in size. The patient became symptom-free and was walking normally at the time of discharge 28 days after her initial presentation. At 59 days after the initial presentation, she was readmitted with complaints of a sudden recurrence of back pain and weakness of both legs. Repeat MRI at this time revealed reappearance of the spinal epidural hematoma at the same level. Operative evacuation of the hematoma was performed 3 days after the diagnosis of the recurrence, with laminoplasty from T1 to T3. At a clinical review conducted 30 months after the operation, the patient remained symptom-free. Idiopathic resolution of a spinal epidural hematoma has previously been reported in 36 patients. However, we found no record in the literature of any case in which an epidural hematoma recurred following earlier MRI-confirmed idiopathic resolution.     

Acute epidural hematoma caused by contrecoup injury

A rare case is presented of acute epidural hematoma in the left frontal region caused by contrecoup injury as a result of occipital contusion. The possible mechanisms are discussed.     

Extensive postoperative epidural hematoma after full anticoagulation: case report and review of the literature

BACKGROUND/OBJECTIVE: A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation. METHODS: Case report. FINDINGS: After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma. RESULTS: Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy. CONCLUSIONS: Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.     

急性自发性椎管内硬膜外血肿的临床特征及治疗

目的:总结急性自发性椎管内硬膜外血肿(acute spontaneous spinal epidural hematoma,ASSEH)的临床和影像学特征,探讨其治疗方法及预后.方法:收集我院2005年1月～2020年12月收治的27例ASSEH患者的临床和影像学资料,回顾性分析病因、临床表现、影像学特征、治疗过程、手...     

Spontaneous cervical epidural hematoma of idiopathic etiology: case report and review of literature

Context

Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to acute onset of neurological deficits, which if not recognized early can have catastrophic consequences. The definition and pathophysiology of this condition remain controversial. High index of suspicion followed by T2-weighted gradient echo sequences are particularly useful in early diagnosis. Management consists of prompt surgical decompression of the hematoma though a recent trend is toward non-surgical treatment.

Findings

A 70-year-old man presented with acute onset neck pain with a radicular component and rapidly progressive quadriparesis. Magnetic resonance imaging revealed a posteriorly located cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery to near normal function occurred within 24 hours of surgery.

Conclusion

SSEH in its true idiopathic form is a rare pathologic entity. Because of the high risk of poor outcome without treatment, SSEH should be a diagnostic possibility when presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis.     

Spinal epidural hematoma

Three cases of spinal epidural hematoma are reported, one lumbar, another cervical, and the third thoracic. All were dorsolaterally localized, the first and the third were dependent on anticoagulant therapy, and the second was spontaneous. In addition to the symptoms of sudden onset, acute spinal pain, flaccid paralysis, and loss of sphincter control, the second case had the exceptional picture of a cervical anterior spinal cord syndrome with preoperative transient improvement, followed by the development of Brown-Séquard syndrome with subsequent deterioration. This case was diagnosed by means of computed tomography. The postoperative course has been satisfactory in all patients, with complete recovery in two.     

针刺治疗引发脊髓硬膜外脓肿2例

<正>患者1,男,42岁,因“背部酸痛10余天,加重伴双下肢麻木无力半天”于2013年1月22号入院。患者10余天前打篮球后出现背部酸痛,自认为肌肉拉伤,休息后症状缓解不明显,遂予以背部针刺治疗。针刺治疗后第2天,患者夜间睡眠时突发双下肢麻木无力,双上肢感觉运动正常。至我院急诊就诊,胸部CT示T₃椎体左旁可见不规则占位性病变。     

Spontaneous cervical epidural hematoma: Report of a case managed conservatively

Spontaneous spinal epidural hematoma is a rare cause of acute spinal cord compression. A 25-year-old male presented with a history of sudden onset of complete quadriplegia with sensory loss below the neck along with loss of bowel and bladder control. He had no history of any constitutional symptoms. He reported 10 days later. He was managed conservatively and after two weeks of intensive rehabilitation he had complete neural recovery.The spontaneous recovery of neurological impairment is attributed to the spreading of the hematoma throughout the epidural space, thus decreasing the pressure with partial neural recovery.Conservative treatment is a fair option in young patients who present late and show neurological improvement. The neurological status on presentation will guide the further approach to management.     

Surgical management of spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity; its causative factors and the factors determining the outcome are still controversial. We reviewed our clinical experiences and analyzed the various factors related to the outcome for SSEH. We investigated 14 patients (11 men and 3 women) who underwent hematoma removal for SSEH from April 1998 to August 2004. We reviewed age, gender, hypertension, anticoagulant use and the preoperative neurological status using the Japanese Orthopaedics Association score by examining medical records, operative records, pathology reports, and radiographies, retrospectively. We were checking for factors such as the degree of cord compression owing to hematoma and the extent and location of the hematoma. Most patients included in the study were in their twenties or fifties. Four hematoma were located in the cervical region (29%), three were cervicothoracic (21%), four were thoracic (29%) and three were in the lumbar (21%) region and also 12 were located at the dorsal aspect of the spinal cord. In all cases, the neurological outcome improved after the surgical operation. There was a statistically significant difference between the incomplete and complete neurological injury for the preoperative status (P<0.05). The neurological outcome was good in those cases that had their hematoma removed within 24 h (P<0.05). The patients with incomplete neurological injury who had a surgical operation performed within 12 h had an excellent surgical outcome (P<0.01). Spontaneous spinal epidural hematoma was favorably treated by the means of a surgical operation. The favorable factors for SSEH operations were incomplete neurological injury at the time of the preoperative status and the short operative time interval.     

Risk factors of postoperative spinal epidural hematoma after transforaminal lumbar interbody fusion surgery

ObjectTo assess the incidence and analyze the risk factors of postoperative spinal epidural hematoma (SEH) after transforaminal lumbar interbody fusion (TLIF) surgery, in order to provide a solution for reducing the occurrence of postoperative SEH after TLIF.MethodsA total of 3717 patients who were performed TLIF surgery in the Orthopedics department of our hospital from January 2010 to March 2020 were included. Patients who had reoperations due to postoperative SEH were selected as the SEH group. The control group was randomly selected from patients without reoperations with the ratio of 3:1 compared to the SEH group. The basic information, preoperative examination and surgical information of the patients were collected through the hospital medical record system, and the statistics were processed through SPSS 22.0 software.Results(1) Among the 3717 patients who underwent TLIF surgery in our hospital in the past 10 years, 46 had secondary surgeries, with a total incidence of 1.24%. 12 cases had secondary surgeries due to postoperative SEH, with an incidence of 0.35%. (2) Univariate analysis identified eight factors potentially associated with risk for postoperative SEH, including older age, longer thrombin time (TT), higher level of alkaline phosphatase (ALP), higher number of fusion segments, revision surgery, having received blood transfusion, using of more than one gelatin sponge or using of styptic powder in the surgery, longer operation time and more blood loss in the surgery (P < 0.05). (3) On multivariate analysis, three factors were identified as independent risk factors, which include revision surgery (P = 0.021, OR = 7.667), longer TT (P = 0.027, OR = 2.586) and using of more than one gelatin sponge or using of styptic powder in the surgery (P = 0.012, OR = 9.000).ConclusionsRevision surgery (P = 0.021, OR = 7.667), longer TT (P = 0.027, OR = 2.586) and using of more than one gelatin sponge or using of styptic powder in the surgery were independent risk factors for postoperative SEH after TLIF.     

Epidural hematoma after thoracic epidural catheter removal in the absence of risk factors

BACKGROUND AND OBJECTIVES: The purpose of this report is to enhance awareness that an epidural hematoma can occur even in patients devoid of risk factors. CASE REPORT: A 69-year-old, 55-kg male was scheduled for video-assisted thoracoscopic resection of bilateral pulmonary metastases and received combined thoracic epidural and general anesthesia. The epidural catheter insertion was unremarkable. All laboratory values were within normal values. No anticoagulation or antiplatelet drugs were administered. The epidural catheter was removed on postoperative day 2. The patient developed signs of an epidural hematoma a few hours later and was treated by decompressive laminectomy. Full neurologic recovery was observed after a 6-month period. CONCLUSION: Catheter removal is a critical period for epidural hematoma formation even if no risk factors are identified. Early recognition and treatment are essential features for good neurologic recovery after an epidural hematoma.     

自发性脊髓硬膜外和硬膜下血肿

目的 探讨自发性脊髓硬膜外血肿（SSEH)及硬膜下血肿(SSSH)的病因、临床特点、诊治方法及预后相关因素。方法 自1995～2002年收治的4例SSEH及2例SSSH患者．均在静息或轻微活动后发病，发病前均无感染或服药史，其中1例63岁患者诉有高血压病史．1例65岁患者入院检查后发现患有Ⅱ型精尿病．余均否认患有其他疾病。所有患者均表现为突发性的颈、肩、胸、背部疼痛，数分钟到数小时内出现肢体运动、感觉障碍、大小便障碍及潴留，5例患者有抻经根放射痛症状．有3例行腰穿，压力无明显增高．均行手术治疗．手术距发病时间10～16d．平均12.5d，手术均在局麻下进行．4例SSEH患者行患部全椎板切除血肿清除术．2例SSSH患者行全椎板切除并硬静膜切开血肿清除，硬脊膜修补术。结果 均经MR检查、手术及病理证实。MRI显示椎管后方或后外方占位性病变，T1加权能特征性地反映血肿随时间发生的信号变化而最有价值．T22加权可很好地判断血肿的位置，患者预后与术前的神经功能状态及发病至手术的时间密切相关，本组患者随访6～18个月，平均10个月．6例患者除大、小便功能有不同程度的改善外．5例患者肢体的运动、感觉功能无明显恢复，1例SSSH患者感觉消失平面下降，右上肢肌力较前增强，结论 自发性脊髓硬膜外及硬膜下血肿是一种少见病，MRI是其首选的检查方法，应当注意的是早期诊断并及时手术是治疗SSEH和SSSH．防止永久性神经功能障碍的关健。     

自发性椎管内硬膜外、硬膜下血肿的诊断和治疗

探讨比较自发性硬脊膜外、硬膜下血肿的出血原因、临床表现、影像特征及治疗预后。结合相关文献,回顾性分析7例自发性硬脊膜外血肿和1例自发性硬膜下血肿的流行病学、发病机制、部位,临床特征、神经功能状态,以及手术,保守治疗和预后。结果有6例患者手术治疗,1例痊愈,2例保守治疗,1例痊愈。自发性硬脊膜外,硬膜下血肿多急性起病,硬脊膜外较硬膜下血肿更为常见,且MRI显示椎管内占位影较CT明显。MRI检查是诊断本病最佳方法。手术减压是改善预后的主要方法。起病到治疗的时间间隔越短预后越好。     

Chronic spontaneous spinal epidural hematoma simulating a lumbar stenosis

Summary A case of a patient with a clinical picture of lumbar spine stenosis actually caused by a chronic, spontaneous, spinal epidural hematoma is reported. There was no history of major or minor trauma to the lumbar spine. The correct preoperative diagnosis was made by magnetic resonance imaging. The possible etiology and clinical and radiological findings and treatment of this rare entity are discussed.     

A new classification for spinal epidural hematoma following microendoscopic decompressive laminotomy: A prospective clinical and magnetic resonance imaging study of 245 patients

ObjectiveThe aim of this study was to develop a new radiological classification system for postoperative spinal epidural hematoma (SEH) using magnetic resonance imaging (MRI) and to determine the correlation of this classification system with clinical and radiological outcomes.MethodsThis prospective study included a total of 245 consecutive patients (126 females, 119 males; mean age=72 years; age range=39–91 years) with single level spinal stenosis who were treated by microendoscopic decompressive laminotomy (MEDL). MRI was performed for all patients 24 hours postoperatively and at 12 months. SHEs were categorized into four grades using our new MRI-based classification system based on the measurement of dural sac area: Grade A, small hematoma with a round shape; grade B, small hematoma that show no round shape; grade C, moderate hematoma; grade D: severe hematoma. Patients were then divided into four groups according to their hematoma grades, Group A, 107 patients with grade A hematomas; group B, 47 with grade B; group C, 67 with grade C; group D, 24 with grade D. Also, patients who had neurological deterioration or who pain resistant to medical treatment were treated surgically, and those were assigned to group H+(14 patients). The study, therefore, contained five groups. Clinical evaluation was done using Japanese Orthopaedic Association (JOA) score preoperatively and at 12 months postoperatively.ResultsNo significant difference existed among groups in the preoperative median measurement of the dural sac area, which were 0.90 cm2 in group A, 0.80 cm2 in group B, 0.70 cm2 in group C, 1.1 cm2 in group D, and 0.80 cm2 in group H+ (p=0.076). At the postoperative 12-month measurement, no significant difference was noted among groups A (2.05 cm2), B (1.80 cm2 ), and H+ (1.90cm2) (A vs B: p=0.891, A vs H+: p=0.089, B vs H +: p=0.933). The measurements were greater in groups A and B than in groups C and D (p<0.05). Also, larger dural sac areas were determined in group H+ (1.90cm2) compared to Groups C (1.80 cm2) and D (1.60 cm2) but the difference reached no statistical significance (p=0.078). In preoperative JOA scores, there were no significant differences among groups (p>0.05). At 12-month JOA scores, no significant difference was observed between groups A and B (p=0.061) and between groups C and D (p=0.511). The scores were higher in groups A and B than in groups C and D (p<0.05).ConclusionIt seems that the narrower the preoperative dural sac area, the better the clinical symptoms of the patients with SEHs based on our new MRI-based classification system. This classification may be useful to predict the clinical status of these patients at one-year follow-up.Level of EvidenceLevel IV, Diagnostic study     

Cervical spontaneous epidural hematoma as a complication of non-Hodgkin's lymphoma

Epidural hematoma is a rare cause of spinal cord compression, which usually provokes severe neurological deficits. It is presumed to originate from venous or, more probably, arterial bleeding. Thrombocytopenia and other disorders of coagulation may precipitate the onset of epidural hematoma and facilitate the evolution of the disease. We report the case of a patient suffering from a non-Hodgkin's lymphoma with severe thrombocytopenia during a MACOP-B schedule, who presented with a spontaneous cervical epidural hematoma. We discuss the etiopathological aspects, diagnosis, and treatment of this rare cause of acute cervical spinal cord compression.