Multiple Sclerosis Care: An Integrated Disease-Management Model

Abstract

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.     

Spontaneous regression of paraplegia caused by spontaneous cervico-thoracic epidural hematoma

Spontaneous spinal epidural hematoma is a rare condition that usually requires surgical treatment in emergency. We report the unusual and well-documented case of a spontaneous spinal epidural hematoma, extending from C6 to T2, occurring in a 56-year old man and causing paraplegia. Without surgery, the paraplegia spontaneously and completely recovered within the first 24 hours. Serial MRI studies demonstrated the remitting course of the spinal epidural hematoma. Emergency surgical evacuation should still be the standard treatment for patients with disabling and/or persistent neurologic deficit. A conservative approach under close neurologic observation may be recommended for patients with no or mild deficits, for patients who show early and continuous clinical improvement within the first 24 hours and for patients with small and/or non-compressive spinal epidural hematoma. Reported cases of spontaneous remission are very rare.     

自发性硬脊膜外血肿的临床特点及预后影响因素分析

目的探讨自发性硬脊膜外血肿（spontaneous spinal epidural hematoma,SSEH）的临床特点以及预后影响因素。方法1998年9月-2006年10月,收治SSEH患者23例。男10例,女13例;年龄10-69岁。神经功能障碍按ASIA分级：A级7例,B级2例,C级4例,D级9例,E级1例。发病至出现明显神经功能障碍时间：〈12h12例,12-24h2例,24-48h3例,〉48h6例。均经MRI检查或病理学检查确诊。17例采用手术治疗,6例采用以甲基强的松龙（80-100mg/d）为主的非手术治疗。回顾患者病史、实验室检查、放射学诊断、病理学检查结果及治疗方法,分析以上因素对患者预后的影响。结果23例随访3个月,恶化1例,无进展8例,改善9例,痊愈5例。性别对预后影响无统计学意义（P〉0.05）;病程进展越快,血肿所覆盖的脊髓节段越多,患者的预后越差（P〈0.05）;神经损害越轻,预后越好（P〈0.01）。手术治疗17例中,预后评分为1分1例,2分5例,3分6例,4分5例;手术前时间与预后的相关系数为0.056（P〉0.05）。非手术治疗6例中,预后评分2分及3分各3例。结论SSEH是一种罕见疾病,其预后受患者神经功能状态、病程进展时间、脊髓是否合并水肿及硬膜外血肿体积等因素影响。此病以手术治疗为主,且宜早期进行,防止脊髓功能进一步恶化。非手术治疗只适用于脊髓功能在早期恢复的患者。     

Effectiveness of suction drainage after primary or revision total hip and total knee arthroplasty.

Postoperative suction drainage of a surgical wound is aimed at evacuation of wound hematoma. This study evaluated the effectiveness of suction drainage in joint replacement surgery. Surgical wounds in 206 patients with primary or revision hip and knee arthroplasty were assessed according to a set criteria. Forty-eight hours postoperatively, wound hematoma and exudate formation were not related to the use of suction drains. A greater tendency of wound oozing was seen in revision hip arthroplasty performed with postoperative suction drainage. Therefore, postoperative suction drainage did not affect hematoma formation or wound oozing and is thus considered an unnecessary practice.     

Can We Prevent a Postoperative Spinal Epidural Hematoma by Using Larger Diameter Suction Drains?

Background

Epidural hematoma is a rare but serious complication. According to previous studies, it is not prevented by suction drains. This study evaluated the following alternative hypothesis: the larger the diameter of a suction drain, the less the remaining epidural hematoma after spinal surgery.

Methods

This was a randomized prospective study. Patients who underwent posterior lumbar decompression and instrumented fusion were divided into two groups: the large drain (LD, 2.8-mm-diameter tube) and small drain (SD, 1.6-mm-diameter tube) groups according to the diameter of the suction drains. All patients were consecutive and allocated alternately according to the date of operations. Suction drains were removed on day 3 and magnetic resonance imaging was performed on day 7 postoperatively. The size of remaining hematomas was measured by the degree of thecal sac compression in cross section using the following 4-point numeric scale: G1, less than one quarter; G2, between one quarter and half; G3, more than half; and G4, more than subtotal obstruction.

Results

There were 39 patients with LDs and 38 with SDs. They did not differ significantly in terms of sex, number of fusion segments, revision or not, antiplatelet medication, intraoperative injection of tranexamic acid. However, patient age differed significantly between the two groups (LD, 63.3 years and < SD, 68.6 years; p = 0.007). The two groups did not differ significantly in terms of prothrombin time, activated partial thromboplastin time, platelet number, blood loss, or operation duration. However, platelet function analysis exhibited a significant difference (LD, 164.7 seconds and < SD, 222.3 seconds; p = 0.002). The two blinded readers showed high consistency (Kappa value = 0.740; p = 0.000). The results of reader 1 were as follows: LD and SD had 21 and 21 cases of G1, 9 and 11 cases of G2, 6 and 6 cases of G3, and 3 and 0 cases of G4, respectively. The results of reader 2 were as follows: LD and SD had 22 and 23 cases of G1, 7 and 9 cases of G2, 7 and 6 cases of G3, and 3 and 0 cases of G4, respectively. There was no difference between the two groups (reader 1, p = 0.636; reader 2, p = 0.466).

Conclusions

The alternative hypothesis was rejected. Therefore, postoperative spinal epidural hematoma would not be prevented by LD.     

Postoperative spinal epidural hematoma at a site distant from the main surgical procedure: a case report and review of the literature

Background ContextPostoperative spinal epidural hematomas are known complications of spinal surgery. However, to our knowledge, there are no known cases of postoperative spinal epidural hematoma that occurred distant from the portion of the procedure that breached the spinal canal.PurposeTo report a case and review the literature on the development of postoperative spinal epidural hematoma at a site distant from the portion of the surgical procedure that breached the spinal canal.Study DesignCase report and review of the literature.MethodsOne patient at our institution developed a hematoma at a site distant from the surgical procedure that breached the spinal canal. We retrospectively reviewed the patient's clinical charts, radiographs, and computed tomography scans.ResultsA 57-year-old woman with adult scoliosis and junctional kyphosis underwent a pedicle subtraction osteotomy and long spinal fusion from T3 to the sacrum. Three hours postoperatively, she developed paraplegia with a neurologic deficit at a level distant from the site at which the spinal canal was surgically breached. A computed tomography myelogram revealed a spinal epidural hematoma that was causing compression of the spinal cord in the upper thoracic spine. The patient was returned to the operating room emergently and underwent laminectomy and hematoma evacuation. She had near-complete recovery 5 months after surgery.ConclusionSpinal epidural hematomas are rare but dangerous complications that can result in severe neurologic deficits. A neurologic examination should always be conducted in the operating room immediately after surgery; if it is abnormal, spinal epidural hematoma should be suspected. If the examination indicates a deficit at a site distant from the original surgery, then diagnostic reimaging (magnetic resonance imaging or computed tomography myelogram) is indicated.     

Optimal timing of wound drain removal following total joint arthroplasty

Closed suction drains reduce postoperative hematoma formation, but create an entry portal for bacteria and thus increase the risk of infection. This study attempts to establish when the risks of wound drainage outweigh the benefits. In a prospective clinical trial, wound drains were used in all patients having a total knee or total hip arthroplasty. Timing of drain removal and amount drained were recorded. Drain-site swabs were sent with drain tips for bacteriology. Results suggest that the likelihood of bacterial colonization increases while wound drainge decreases with time. The authors conclude that the optimal time to remove drains is 24 hours after total joint arthroplasty.     

Multilevel acute spinal epidural hematoma in a patient with chronic renal failure--case report

A 47-year-old female with diabetic nephropathy presented with acute onset of severe back pain and progressive weakness in both lower extremities. Neuroimaging revealed a spinal epidural hematoma extending from the T-3 vertebra to the sacrum. Removal of all or every other lamina on levels with epidural hematoma and emergent evacuation of the hematoma were planned. T-9 and T-10 laminectomies were performed, but excessive bleeding during the operation prompted us to abandon the procedure. Plasma and desmopressin administration controlled the bleeding from the drain 8 hours after the operation. Follow-up neuroimaging one month later revealed total resolution of the hematoma with improved neurological status. Acute spinal epidural hematomas extending over more than 15 segments are extremely rare and the surgical treatment is still challenging. Coexisting hemorrhagic diathesis creates more problems. Conservative treatment may be the best option.     

胸椎手术后急性硬脊膜外血肿

 目的 探讨胸椎手术后急性硬脊膜外血肿的形成原因、血肿压迫时间对脊髓神经功能的影响及预防措施。方法 回顾性分析2002年5月至2012年5月经手术证实的胸椎后路手术后发生急性硬脊膜外血肿致神经功能障碍的14例患者资料,男6例,女8例;年龄41～69岁,平均61.2岁;胸椎管狭窄症10例,胸椎管内脊膜瘤3例,胸椎转移瘤1例;胸椎后路手术后3～14 h,平均6.6 h,患者脊髓神经功能出现恶化,ASIA分级A级5例,B级9例。对比血肿清除前、后以及随访时患者神经功能评分及神经功能恢复率。分析神经功能恢复率与血肿压迫时间及血肿清除前神经功能的关系。结果 14例患者血肿清除后AISA分级为：B级1例,C级2例,D级4例,E级7例。其中B、C级3例患者血肿压迫时间均 ＞10 h。血肿清除前、后神经功能比较差异有统计学意义,血肿清除后神经功能恢复率为63.7%±23.3%,与血肿压迫时间呈负相关,与血肿清除前神经功能呈正相关。血肿清除前神经功能与随访神经功能比较差异有统计学意义,随访神经功能恢复率为86.97%±17.58%,与血肿压迫时间呈负相关,与血肿清除术前神经功能呈正相关。结论 胸椎术后急性硬脊膜外血肿可致脊髓神经功能严重损害。脊髓神经功能恢复与血肿压迫时间有直接关系。早期诊断并清除血肿压迫是挽救脊髓功能的关键。     

Thunderclap headache as a presentation of spontaneous spinal epidural hematoma with spontaneous recovery

Abstract

Background

Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord compression disorder. Thunderclap headache mimicking subarachnoid hemorrhage as an initial manifestation of this disorder has been scarcely reported. Moreover, the neurological outcome of conservative treatment is satisfactory only in some clinical settings. The unusual presentation and mechanisms for spontaneous recovery of SSEH are discussed.

Objective

To report a case of SSEH that presented with acute severe headache that mimicked subarachnoid hemorrhage. After a period of neurological deficit, spontaneous improvement was seen, which progressed to full recovery without neurosurgical intervention.

Findings

A 62-year-old man presented with acute occipital headache and neck stiffness for which subarachnoid hemorrhage was initially suspected. An emergency computed tomographic brain scan and cerebrospinal fluid analysis excluded subarachnoid hemorrhage. Later, he developed acute paraparesis, hypoesthesia up to the fourth thoracic dermatomal level (T4) as well as bowel and bladder dysfunction. The magnetic resonance imaging eventually revealed spinal epidural hematoma, located anterior to C7 through T4 spinal level. He had no previous history of spinal injury, systemic, and hematological disorders. The neurological recovery began 20 hours after the onset and continued until complete recovery, 4 months after the onset without neurosurgical intervention.

Conclusion

SSEH could sometimes imitate subarachnoid hemorrhages when it located in the cervical region. Spontaneous recovery of SSEH without surgical intervention might be possible in cases with continuing neurological recovery, although the recovery began much later in the clinical course.     

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.     

Extensive Postoperative Epidural Hematoma After Full Anticoagulation: Case Report and Review of the Literature

Abstract

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.     

Spinal cord infarction after decompressive laminectomy for spontaneous spinal epidural hematoma--case report

A 68-year-old woman presented to the emergency department for evaluation of bilateral leg weakness. On admission, she had paraparesis with incomplete sensory deficit. Magnetic resonance (MR) imaging of the thoracolumbar spine revealed spontaneous spinal epidural hematoma (SSEH) compressing the spinal cord. The patient was taken to the operating room for urgent surgical decompression and evacuation of the SSEH. After the surgery, she woke up with complete paraplegia. Postoperative MR imaging showed the spinal cord was edematous, with minimal remnant hematoma. MR imaging after 1 month clearly showed anterior spinal artery thrombosis. No significant neurological improvement occurred during the 3-month follow up. Surgeons should consider the possibility of this devastating complication before aggressive and early surgical intervention in a patient with SSEH causing cord compression and neurological deficit.     

Influence of Postoperative Hypertension on the Development of Spinal Epidural Hematoma

Spinal epidural hematoma (SEH) is a rare postoperative complication but can result in catastrophic neurological deficits requiring immediate surgical evacuation of the hematoma. Knowing the risk factors for postoperative SEH can help surgeons stratify patients. Therefore, to identify possible risk factors for postoperative SEH, we reviewed 6 clinical cases and examined the relation between postoperative hypertension and the risk of developing SEH. A retrospective review was conducted of 1282 consecutive patients who underwent spinal surgery at a single institution between 2010 and 2015. Of this cohort, 6 patients developed symptomatic SEH and underwent emergency hematoma evacuation. The 6 SEH patients were evaluated for previously described risk factors of postoperative hematoma formation. In particular, postoperative blood pressure measurements were reviewed. The incidence of postoperative symptomatic SEH was 0.468%. Two patients developed SEH secondary to a nonfunctional surgical drain in the early postoperative period (5 or 12 h post‐surgery). Preoperative and postoperative hypertension was observed in 4 patients who developed SEH at greater than or equal to 48 h following surgery. Our findings suggest that rigorous postoperative blood pressure control may decrease the risk of SEH.     

Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

Background

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

Methods

Case report and literature review.

Findings

A previously healthy man presented with Brown-Séquard syndrome below T5–T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

Conclusions

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.     

Paraplegia Subsequent to Administration of Tissue Plasminogen Activator and Intravenous Heparin Following Myocardial Infarction-A Case Report

Abstract

A case involving spinal epidural hematoma following tissue plasminogen activator and intravenous heparin therapy administered after acute myocardial infarction is reported here. The symptoms of spinal epidural hematoma following thrombolytic therapy are outlined and a recommended course of action for arriving at a definitive diagnosis of suspected epidural hematoma is provided.     

The management of "asymptomatic" epidural hematomas. A prospective study

Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma. Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol. It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.     

The influence of the drain suction in knee arthroplasty

PROBLEM: In a prospective randomised clinical study, we investigated the impact of drain-suction on the post-operative blood loss and on both clinical and laboratory parameters after knee replacement operations. PATIENTS AND METHOD: In this study, 116 patients with unilateral implantation of knee replacements were evaluated. The patients' average age was 71.2 years. The operation was carried out mostly without tourniquet application. All patients received two wound drains, 57 with and 59 without suction. The postoperative blood loss as well as clinical and laboratory parameters were assessed. RESULTS: The average peri-operative blood loss amounted to 338 ml. The post-operative blood loss in the group without drain suction was 436 ml and 528 ml in the group with suction. No significant differences could be found concerning the hemoglobin values pre-operatively and on the first and seventh post-operative day, the drainage quantity 12, 24, 36, and 48 hours post-operatively, the wound healing and the CRP. Six patients in the group without and five patients in the group with drain-suction had to receive blood transfusions. DISCUSSION: The application of suction on the drainage system had no significant impact on the post-operative blood loss and the postoperative course. In nine out of ten cases no homologous blood was needed.     

Deep Venous Thrombosis in Spine Surgery Patients: Incidence and Hematoma Formation

Deep venous thrombosis (DVT) is a significant health care problem; a variety of factors place spinal surgery patients at high risk for DVT. Our aim is to define the incidence of DVT occurrence in spite of prophylactic measures (mechanical and chemoprophylaxis), and the development of spinal epidural hematoma as a complication of chemoprophylaxis. In a single-center prospective study, 158 patients who underwent spinal surgical procedures were evaluated by clinical evaluation and lower limb Doppler ultrasonography imaging. Only one patient (0.6%) developed DVT; this patient was treated successfully without thrombus progression, with full recanalization. Three patients (1.8%) developed spinal epidural hematoma, but only one required surgical evacuation, and none sustained neurologic deficit. Careful evaluation for DVT risk on an individual basis and good prophylaxis helps to minimize the risk of DVT. The neurosurgeon is thus left to weigh the risks of postoperative hematoma formation against the benefits of protecting against DVT.     

胸椎椎管狭窄症术后急性硬脊膜外血肿

目的探讨胸椎椎管狭窄症术后急性硬脊膜外血肿的成因、诊断、治疗及预防措施。方法回顾性分析2003年6月～2011年12月因胸椎椎管狭窄症给予后路全椎板减压手术的患者101例,其中术后经再次手术证实术区急性硬脊膜外血肿9例,对其临床表现与再次手术情况进行分析。结果 9例患者全部获得随访,随访时间为3～45个月,平均34个月。血肿清除前神经功能评分为0.89±0.78,血肿清除后的神经功能评分为2.33±1.22,与术前相比差异有统计学意义（t=4.91,P〈0.01）。硬膜外血肿压迫时间为（7.72±7.06）min,血肿清除后神经功能恢复率与血肿压迫时间呈负相关（r=-0.789 6,P〈0.01）。结论胸椎椎管狭窄症手术后急性硬膜外血肿应尽快手术减压,血肿清除越早,术后神经功能恢复越好。