Abstract
Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy.The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia.If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.
Highlights
Hemorrhagic diseases in the spinal canal are roughly classified into intraspinal, epidural, subdural, and spinal subarachnoid hemorrhage
If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery
Most subdural hematomas are triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors
Summary
Hemorrhagic diseases in the spinal canal are roughly classified into intraspinal, epidural, subdural, and spinal subarachnoid hemorrhage. Lower limb MMT had decreased to 3/5 on the right side below the tibialis anterior muscle, and the left was still 2/5 This progression of bilateral lower limb paralysis led to the decision to perform emergency surgery 14 hours after the onset of symptoms. T2-weighted images of the lower thoracic cord to the conical spinal cord area showed a low signal, suggesting hemosiderin deposition No obvious abnormalities such as vascular malformations were observed. Paralysis of both lower limbs recovered over time, and the patient was able to walk with a brace on her left ankle four weeks after surgery, and to walk independently five weeks after onset. Thoracic spine MRI of the spinal cord showed a highintensity region at the upper Th3 level on a T2-weighted image, but the hematoma had disappeared (Figures 8-10). The high-intensity region in the spinal cord of the Th2-weighted image at the higher position of Th3 remained, but the hematoma disappeared
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