Cyclic alternation of paraplegia and leg pain as symptoms of a giant spontaneous spinal epidural haematoma.

Abstract

Dear Editor, Spontaneous spinal epidural haematoma (SSEH) is a neurosurgical emergency and can occur due to spinal arteriovenous malformations, haemangiomas or rupture of epidural venous plexus favoured by coagulation disorders. The initial symptoms include back pain with radicular or pseudoradicular irradiation which can progress to neurological signs of complete spinal cord compression [2, 6]. Prognostic factors for recovery after surgical decompression include preoperative neurological deficits, extent of affected vertebral segments, radiological signs of spinal cord compression and the interval between symptom onset and surgery [1, 3–5, 7]. We would like to bring your attention to a new set of fluctuating symptoms heralding the diagnosis of SSEH. A 60-year-old gentleman with a previous medical history of alcoholic liver disease and splenomegaly (thrombocytes at 64G/l, PT and aPTT within normal range) was transferred to our department after falling in the street at night. For the following 3 weeks he could not move his legs when waking up in the morning. It was only after sitting upright in his bed for about 5min that he regained control of his legs and was able to walk. However, in the course of the day he developed bilateral pseudoradicular pain throughout the day. There was a cyclic alternation between symptoms of paraparesis in the morning and diurnal pseudoradicular irradiation. On clinical examination he had a severe paraparesis and was classified as ASIA B. MRI demonstrated an epidural collection compressing the spinal cord posteriorly from Th-3 to L-5 (Fig. 1a). Platelet substitution and subsequent surgical evacuation led to an improvement of symptoms and MRI showed no residual haematoma (Fig. 1b). Five months after surgery he was ambulatory without residual weakness. This case highlights that SSEH can have an unusual course with long-lasting symptoms. Missed or delayed diagnosis of spinal epidural haematoma is correlated with poorer outcomes [5]. Sharper description of clinical signs could contribute to earlier diagnosis and surgical treatment. Thus, we would like to introduce and emphasise “cyclic alternating leg palsy and pain” as a sign of dynamic spinal epidural compression. Our patient showed an interesting fluctuation of symptoms: in the morning (after lying in horizontal position), he could not move or feel his legs, but after sitting up for a few minutes (verticalisation), he felt his feet again and was able to walk after 15min. The fluctuation of symptoms in this patient may have several explanations. In SSEH, three variable compartments (CSF, blood and the haematoma) contribute to the pressure equilibrium within in the spinal canal. In the upright position, a gravitational shift of the liquid haematoma compartment may have led to a pressure relief of the spinal cord and therefore an improvement of symptoms. This fluid shift hypothesis would be compatible with the rapid time course of symptom resolution. Alternatively, the fluctuation of symptoms could hypothetically be ascribed to positional venous blood congestion with subsequent compression or decreased perfusion of the cauda equina or conus medullaris. A giant SSEH can produce paraparesis in the morning, which resolves to turn into a radicular-pain-like syndrome during the day. Prompt recognition of warning signs for B. Schatlo (*) Department of Neurosurgery, Georg-August University Gottingen, University Medicine Gottingen, Gottingen, Germany e-mail: schatlo@gmail.com