急性硬脊膜外血肿的诊治特点

目的探讨急性硬脊膜外血肿的病因、临床诊治特点。方法分析近15年来经手术治疗的38例急性硬脊膜外血肿的病因、临床表现、MRI/DSA影像学及显微手术特点。结果38例病人均行MRI检查,28例直接手术清除血肿;10例行DSA检查,6例先行硬脊膜动静脉瘘(AVF)供血动脉栓塞,再手术清除血肿并切除瘘口,1例患者术前诊断急性硬脊膜外血肿,术后病理证实为脊髓结核急性期。随访2~9年。神经系统恢复到正常情况的13例;有轻度神经系统改变但生活可以自理的19例;需他人帮助者4例;2例因血肿压迫时间长,术后双下肢瘫痪及尿潴留未改善;本组无死亡病例。结论急性硬脊膜外血肿的早期诊断和早期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。     

Spinal Epidural Hematoma after Pain Control Procedure

Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.     

Spontaneous spinal epidural hematoma during pregnancy

BACKGROUND: Spontaneous spinal epidural hematoma is a rare phenomenon that has no distinct etiology. Spontaneous spinal epidural hematoma (SSEH) during pregnancy is extremely rare. We present what we believe to be the fifth reported case of spontaneous spinal epidural hematoma associated with pregnancy in the English literature. METHODS: A 31-year-old female presented with acute onset of paraplegia at 32 weeks of pregnancy. The patient had a T2 sensory level and complete paralysis of all lower extremity motor groups. Magnetic resonance imaging of the thoracic spine showed an acute epidural hematoma posterior to the thoracic spinal cord between the second and fourth thoracic vertebrae. RESULTS: The patient was taken to the operating room were her child was delivered by caesarean section. She then underwent a posterior laminectomy and evacuation of a spinal epidural hematoma. Follow-up selective spinal angiography was negative for any vascular malformation. The patient gradually recovered lower extremity function and was independently ambulating at six month follow-up. Voluntary bowel and bladder function returned within four months but twice daily intermittent catheterization remained necessary for excessive post-void residual urine. CONCLUSIONS: Spontaneous spinal epidural hematoma in pregnancy is a rare phenomenon. It is postulated that elevated venous pressure associated with pregnancy may be a contributing factor. In the reported cases of SSEH in pregnancy most patients presented with acute symptoms, thoracic location and profound neurological deficits but, with prompt surgical treatment, generally had good long term recovery.     

自发性硬脊膜外血肿的诊断和治疗策略

目的探讨自发性硬脊膜外血肿的临床特征、治疗及影响预后的因素。方法对16例自发性硬脊膜外血肿患者的临床特征、手术治疗时机以及手术后神经功能恢复情况进行回顾总结,并结合文献分析影响预后的因素。所有自发性硬脊膜外血肿患者均行MRI检查。结果16例患者的硬脊膜外血肿分别位于下颈段（2例）、颈胸段（6例）、胸段（7例）及胸腰段（1例）。MRI检查T1WI表现为等信号或略高信号,T2WI以高信号为主,其中可见混杂低信号。12例施行手术治疗的患者中10例预后良好;4例保守治疗者中3例神经功能完全恢复。结论脊髓MRI检查是诊断自发性硬脊膜外血肿的首选方法,早期诊断和外科手术治疗是恢复神经功能、提高疗效的关键。手术疗效主要与自发性硬脊膜外血肿患者手术前的神经功能缺损程度和手术间隔时间有关;症状较轻者在密切观察下可予以保守治疗,其神经功能的恢复主要取决于神经功能缺损程度。目的探讨自发性硬脊膜外血肿的临床特征、治疗及影响预后的因素。方法对16例自发性硬脊膜外血肿患者的临床特征、手术治疗时机以及手术后神经功能恢复情况进行回顾总结,并结合文献分析影响预后的因素。所有自发性硬脊膜外血肿患者均行MRI检查。结果16例患者的硬脊膜外血肿分别位于下颈段（2例）、颈胸段（6例）、胸段（7例）及胸腰段（1例）。MRI检查T1WI表现为等信号或略高信号,T2WI以高信号为主,其中可见混杂低信号。12例施行手术治疗的患者中10例预后良好;4例保守治疗者中3例神经功能完全恢复。结论脊髓MRI检查是诊断自发性硬脊膜外血肿的首选方法,早期诊断和外科手术治疗是恢复神经功能、提高疗效的关键。手术疗效主要与自发性硬脊膜外血肿患者手术前的神经功能缺损程度和手术间隔时间有关;症状较轻者在密切观察下可予以保守治疗,其神经功能的恢复主要取决于神经功能缺损程度。     

Epidural Hematoma Producing Brown-Sequard Syndrome: A Case Due to Ruptured Hemangioma with Magnetic Resonance Imaging Findings

A man developed spontaneous spinal epidural hematoma secondary to ruptured hemangioma with a clinical picture resembling acute partial Brown-Sequard syndrome. Diagnosis by magnetic resonance imaging (MRI) allowed prompt surgical decompression and complete reversal of the neurological deficits. The diagnosis, etiology, and MRI findings of spinal epidural hematomas are discussed.     

Two children with traumatic thoracic spinal epidural hematoma

Traumatic spinal epidural hematomas in children are uncommon. Early diagnosis and prompt surgical evacuation is critical in these patients. We report two children with traumatic thoracic spine epidural hematomas with remarkable neurological recovery after surgical evacuation. Epidural hematoma with significant cord compression requires early diagnosis and emergency evacuation. This is crucial to expedite neurological recovery.     

Acute spinal epidural hematoma in MRI-CT, following continuous epidural anesthesia with spontaneous recovery

We report a case of acute spinal epidural hematoma diagnosed by MRI-CT. A 76-year-old woman was admitted in our hospital for the purpose of the gastrectomy against her early cancer of stomach. Thoracic epidural anesthesia (Th8/9) was attempted for the operation and soft tube was continuously remained in the epidural space after successful gastrectomy. On the second day after operation, the tube was pulled out from the epidural space safely. However, the patient complained severe thoracic-back pain and complete paraplegia of legs with sensory loss beneath Th10 level of dermatoma. X-ray CT and MRI-CT showed spinal epidural hematoma, especially MRI-CT made clear the relationship between spine and hematoma and the level of longitudinal expansion. The hematoma was recognized in MRI-CT as high signal intensity spindle-shape area (spine echo Tr/Te 1800/100). The spinal epidural hematoma existed from 4th to 12th thoracic vertebra level on sagittal slice. Her symptom recovered completely about three hours and a half after the onset spontaneously, and there is no recurrence of paraplegia. The mechanism of spontaneous recovery from paraplegia is assumed that the spreading of the hematoma in epidural space up- and downwards to the rostro-caudal direction results in decompression. Acute spinal epidural hematoma occurred by continuous epidural anesthesia, and with spontaneous recovery is very rare. The hematoma disappeared in MRI-CT on the 26th day after the onset. MRI-CT is useful to detect spinal epidural hematoma safely and accurately for its diagnosis.     

Acute Cervical Subdural Hematoma with Quadriparesis after Cervical Transforaminal Epidural Block

Cervical epidural steroid injection is frequently used in the conservative management of neck pain and cervical radiculopathy. Epidural cervical transforaminal injections are usually well-tolerated with mild side effects such as transient decreased sensory and motor function, or headache due to dural puncture. Although there are a few case reports about adverse effects of cervical epidural injection in the literature, it can cause severe complications such as large hematoma, infarction by spinal vascular injury. Subdural hematoma has been occurred much less common rather than epidural hematoma in the spinal cord. We report a rare catastrophic case of cervical spinal subdural hematoma with quadriparesis after cervical transforaminal epidural block.     

Acute thoracic epidural hematoma following spinal manipulative therapy: case report and review of the literature

Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented.     

Spinal epidural hematoma as a stroke mimic

PurposeSpinal epidural hematoma is a rare but important disease as it can be a stroke mimic. Our aim was to investigate the clinical characteristics of patients with an activated stroke code and spinal epidural hematoma.MethodsPatients with an activated stroke code were examined retrospectively. Patients with spinal epidural hematoma were evaluated with further neurological examinations and neuroimaging.ResultsOf 2866 patients with an activated stroke code, spinal epidural hematoma was detected in 5 (0.2%, 63–79 years, 2 men). In all 5 cases, hematoma was located in the unilateral dorsal region of the spinal canal and spread to 5–9 vertebral segments at the C1–T3 level. None of the patients had a medical history of head or neck injury, coagulopathy, or use of anti-thrombotic agents. All of the patients had occipital, neck, and/or back pain, and their hemiparesis occurred simultaneously or within 1 h after the onset of pain. Hyperalgesia ipsilateral to the hematoma was observed in 1 patient, hypoalgesia contralateral to the hematoma was observed in 1, and quadriparesis and bilateral hypoalgesia were observed in 1. The hematomas spontaneously decreased in size in 4 patients, and cervical laminectomy was performed in the other patient. In the 1860 patients with an activated stroke code and spontaneous eye opening, the sensitivity of pain as a predictor of spinal epidural hematoma was 100%, with a specificity of 88.7%, and positive predictive value of 2.3%.ConclusionPatients with spinal epidural hematoma could present with clinical characteristics mimicking ischemic stroke. Spinal epidural hematoma should be differentiated in patients treated under stroke code activation.     

Unintended Complication of Intracranial Subdural Hematoma after Percutaneous Epidural Neuroplasty

Percutaneous epidural neuroplasty (PEN) is a known interventional technique for the management of spinal pain. As with any procedures, PEN is associated with complications ranging from mild to more serious ones. We present a case of intracranial subdural hematoma after PEN requiring surgical evacuation. We review the relevant literature and discuss possible complications of PEN and patholophysiology of intracranial subdural hematoma after PEN.     

Non-traumatic spinal epidural hematomas (2 cases): contribution of the CT scanner

Two cases of non-traumatic epidural hematoma are reported. The first case, a 76 year old woman receiving anticoagulant treatment, presented with paralysis of both lower limbs and right upper limb. Myelography and CT scan showed a widespread hematoma from C4 to T2. The second patient, a 63 year old hypertensive woman, developed flaccid paraparesis with urinary retention, myelography and CT scan showed an epidural hematoma extending from T12 to L2. In both cases, surgical evacuation was followed by a fair motor recovery. The 190 published cases of non-traumatic spinal epidural hematoma include 14 of precise etiology, 69 idiopathic and 107 associated with or 2 predisposing factors. Three mechanisms are proposed to explain the spontaneous cases: alteration of peridural veins; rupture of dural vascular clusters; minimal arterial injury. CT scan imaging shows a biconvex, hyperdense epidural image and is the investigation of choice for acute, hyperalgesic myelo-radicular compression syndromes.     

Acute cervical spinal epidural hematoma during antithrombotic therapy: dual warnings against antithrombotic therapy]

Two aged women suddenly suffered from severe cervical and back pain followed by ipsilateral hemiparesis sparing the face. One woman had taken anticoagulant for prosthetic mitral valve and another had taken antiplatelet for prevention of recurrent brain infarction. On admission, MRI did not document any definite lesions in the brain, and revealed epidural hematoma compressing the cervical spinal cord for both patients. We promptly stopped their anticoagulants and antiplatelets use, because the agents seemed to be the leading cause of hematoma. In addition, we performed emergent laminectomy and evacuation of hematoma for the former patient. These cases suggest dual warnings against recently prevalent antithrombotic therapy for patients with histories of thromboembolic accidents. First, we should be careful about spinal epidural hematoma as a hemorrhagic complication of antithrombotic therapy. Second, we should not misdiagnose spinal epidural hematoma as ischemic stroke nor select hyperacute thrombolytic therapy. Cervical pain and hemiparesis sparing face are important signs for distinction of spinal epidural hematoma from stroke.     

Extended spontaneous spinal epidural anterior hematoma over multiple spinal segments. A case report]

We reported a case of extended spontaneous spinal epidural hematoma over multiple spinal segment. A 68-year-old man presented with sudden onset of back pain. He rapidly developed tetraplegia within 15 minutes. On admission, he showed tetraplegia, sensory loss below C4 dermatome, right Horner's sign and bilateral Babinski's signs. These neurological signs gradually improved and disappeared completely within 5 hours. MR imaging showed extended hematoma in the anterior part of spinal epidural space. Spinal angiogram showed no vascular anomaly. The patient had nine years history of antiplatelet therapy, which would produce this episode of the spinal epidural hematoma. The hematoma located in the anterior part of the epidural space and extended over multiple spinal segments was characteristic features in this case. In the case which could have early neurological recovery, conservative therapy might be indicated.     

Chronic Spinal Epidural Hematoma Related to Kummell's Disease

Chronic spinal epidural hematoma related to Kummell''s disease is extremely rare. An 82-year-old woman who had been managed conservatively for seven weeks with the diagnosis of a multi-level osteoporotic compression fracture was transferred to our institute. Lumbar spine magnetic resonance images revealed vertebral body collapse with the formation of a cavitary lesion at L1, and a chronic spinal epidural hematoma extending from L1 to L3. Because of intractable back pain, a percutaneous vertebroplasty was performed. The pain improved dramatically and follow-up magnetic resonance imaging obtained three days after the procedure showed a nearly complete resolution of the hematoma. Here, we present the rare case of a chronic spinal epidural hematoma associated with Kummell''s disease and discuss the possible mechanism.     

Spine and spinal cord emergencies: vascular and infectious causes

This content presents infectious and vascular spinal emergencies, including epidural abscess, nontraumatic epidural hematoma, vascular malformations, and spinal cord infarction. The spine is subjected to multiple potential insults, such as trauma, infection, ischemia, hemorrhage, tumor, inflammation, and degeneration. All of these processes can lead to the sudden onset of neurologic symptoms, such as motor weaknesses, bowel and bladder incontinence, and sensory changes. Therefore, prompt recognition of these entities is important to reverse or minimize potential neurologic injury. The authors discuss several infectious and vascular spinal emergencies, including epidural abscess, nontraumatic epidural hematoma, vascular malformations, and spinal cord infarction.     

Transient Brown-Séquard syndrome due to spontaneous spinal epidural hematoma

Spinal epidural hematoma (SEH) is a low incidence injury. When the cause of bleeding is unknown, which occurs in 50% of the cases, we refer to it as spontaneous SEH. The clinical presentation is characterized by acute radicular pain followed by cord compression syndrome. Brown-Séquard syndrome is exceptional as a result of a SEH. Although standard treatment is prompt surgical evacuation of the hematoma, spontaneous resolution has also been reported. We present a case of spontaneous SEH in a 69 year-old man. An MRI revealed an hematoma in the right posterior epidural space extending from C6 to T2. The hematoma was manifested as a paresis of the right limbs and sensory loss of the left side below C7 level. During the first hours the neurological deficit was improved without treatment and consequently a conservative management was continued. After 72 h, the patient was completely recovered. We have reviewed the 14 cases of spinal epidural hematoma and Brown- Séquard syndrome previously reported, only 2 of them were resolved by conservative management. We conclude that when SEH presents as Brown-Séquard syndrome it usually has a more benign course and that in some cases a conservative management can be considered.     

3D打印技术在硬膜外血肿手术中的应用

目的探讨3D打印技术在硬膜外血肿手术中的初步应用。 方法选取山东省滨州市阳信县人民医院神经外科自2016年1月至9月收治的2例硬膜外血肿患者,获取颅脑CT扫描的原始数据,制作硬膜外血肿的三维模型和与头面部组织完全贴合的"盔甲"三维模型,依据硬膜外血肿在"盔甲"模型的投影进行剪切,得到硬膜外血肿的范围,通过3D打印实体化得到手术模具。设计合理的手术切口进行手术,观察术后治疗效果。 结果患者术后复查CT显示血肿清除比较彻底,无迟发性出血;术前剧烈头痛、意识障碍及肢体偏瘫等颅内高压症状消失。随访6个月,患者恢复正常生活及社交,GOS评分5分。 结论应用3D打印技术进行模具打印,能够对硬膜外血肿进行精确定位,评估手术风险,选取合理的手术入路,降低手术创伤,解除血肿压迫。     

Anterior spinal epidural hematoma: a case report

PURPOSE: to present a case of post traumatic anterior spinal epidural hematoma. CASE REPORT: a 55-year-old man presented with abrupt onset of paraparesia following a motor vehicle accident. Magnetic resonance imaging showed an anterior lumbar epidural hematoma. Surgical evacuation of the hematoma resulted in complete recovery.     

Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases

Three patients with a spontaneous spinal epidural hematoma are presented, one of which is exceptional because it could be attributed to thrombolysis with alteplase. The other two were correlated with oral anticoagulant therapy. Our second case suggests that Morbus Kahler may be an underlying pathology in spinal extradural hematoma. In the third patient neither an obvious ‘locus minoris resistentiae' nor a pathological coagulation test could be held responsible for the spontaneous bleeding. All three patients underwent laminectomy and evacuation of the hematoma. Although two of our cases are examples of complete recuperation after late operative intervention, early surgery is preferable. Permanent clinical attention together with a low threshold to perform magnetic resonance imaging (MRI) leads to a quicker diagnosis of spinal epidural hematoma. We show that administration of gadolinium may facilitate correct preoperative localization of the hematoma because there may be contrast enhancement of the hematoma. Finally, the postoperative policy concerning thromboembolic prophylaxis is discussed.