Chronic extradural spinal hematoma after previous trauma

Abstract

Dear Editor, Spinal chronic extradural hematomas are extremely rare and become clinically relevant when they affect the spinal cord and/or nerve roots causing neurological symptoms [1], [2]. A 53-year-old male presented to our hospital with a 9-month history of pain following an accidental trauma (sudden fall from a chair). He experienced a gradual onset of low back pain and also complained of mild neurogenic claudication. Nevertheless he was treated with anti-inflammatory medications and physical therapy; the symptoms gradually worsened and at the moment of admission in our hospital he showed relevant claudication and disestesias. Physical exam revealed a normal lumbar range of motion and the absence of muscolotendinous reflexes in the lower limbs without motor deficit or sphincter disturbance. An MRI of the dorsal and lumbar spine was performed and revealed a round mass in the vertebral canal at L1 level (Fig. 1). The mass showed hypointense signal on T2 weighted image and Stir sequences (hemosiderin deposition) (Fig. 2, Fig. 3), with no enhancement on gadolinium administration (Fig. 4) and with no actual bleeding on gradient-echo sequences and it did not disrupt the longitudinal posterior ligament (Fig. 5). Because of the clinical and radiological findings, a surgical procedure was performed. Operation neurosurgeons performed partial laminectomy of L1 and removed the extradural hematoma (Fig. 6). The patient was discharged after few days without relevant neurological problems but for a brief period he was admitted to a rehabilitation center. Histopathological examination revealed a chronic hematoma and the bacterial culture showed no sign of infection. Epidural spinal hematomas depend on a variety of situations and can be divided into two types: acute and chronic. Chronic SEHs are rarer than acute SEHs. The former ones are common in spinal surgery but rarely produce neurological deficits [3]. The chronic hematomas, on the other hand produce some neurological symptoms (parestesie, claudication, etc.). For this reason even if rare spinal extradural chronic hematoma has to be considered in the differential diagnosis of nerve roots pain [4], [5], [7]. It is important to collect data from patient history (i.e. previous trauma) and to perform a clinical evaluation and then an MR spinal exam. The common site of a spontaneous chronic hematoma in the few articles reported in the literature is the thoracolumbar region [1], [2], [4], [5], [8]. Hematoma seems to originate from the rupture of Batson's plexus in the epidural space due to changes in venous pressure generally after trauma. The usual clinical presentation of a spinal chronic extradural hematoma is back pain that progresses toward disestesias, depending on the level of the lesion and the nerve roots. Currently MRI is considered the first diagnostic method for study an extradural spinal hematoma and the diagnostic study includes sagittal and axial T1, T2, Stir and gradient-echo and contrast enhancement sequences. The MRI findings of chronic SEHs are helpful for making accurate diagnosis of this pathology but not always conclusive [8]. Surgical intervention is the general treatment for spontaneous spinal epidural haematomas. The procedure includes decompressive laminectomy and hematoma removal [6]. Conservative treatment has also been documented and it is employed when neurological deficits are not worsening or in elderly patients. Fig. 1 Sagittal T2: show extradural hypointense hematoma at L1–L2 level. Fig. 2 Axial T2: show extradural hypointense hematoma at L1–L2 level. Fig. 3 Sagittal T1: show extradural isointense hematoma at L1–L2 level. Fig. 4 Sagittal fat-sat: show ipo-isointense hematoma at L1–L2 level. Fig. 5 Sagittal fat sat MDC: show isointense hematoma with no contrast enhancement. Fig. 6 Axial and sagittal T2 post-surgery: show complete removal of the hematoma.