Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

Abstract

Spinal epidural hematomas (SEH) are a rare hemorrhagic event occurring after trauma, epidural anesthesia, or operative inventions. However, in 40–50% of cases, they occur spontaneously. Spontaneous spinal epidural hematomas (SSEH) are rare in occurrence with an estimated incidence of 1 case per million annually. Pregnancy is an independent risk factor. Sudden neck or back pain, often in combination with a rapid onset of neurological symptoms, is the most common presentation of SEH (1). A 36-year-old Caucasian female with rheumatoid arthritis (RA) presented to the emergency department approximately 48 h after an uncomplicated vaginal delivery. She sought medical attention due to constant headaches and neck pain that started during active labor. An MRI of the spine revealed an extensive SEH spreading from C1 to L5. The patient was without neurological symptoms or deficits and was successfully treated conservatively without any sequelae. Even though the definitive cause of this case of SEH will remain unknown, several possible synergistic mechanisms have been identified. These include female gender, full-term pregnancy, physical activity with increased intraabdominal pressure (i.e., Valsalva maneuver), systemic administration of platelet aggregation inhibitor (PAI), and iatrogenic manipulation such as spinal epidural anesthesia. Even though autoimmune and inflammatory disorders have been described in the literature to be rare sources of hemorrhage in the spinal canal, it is unclear whether the patient’s RA should be regarded as an individual risk factor.Key FactsSpinal epidural hematomas are a rare hemorrhagic event characterized by an accumulation of blood between the vertebrae and the dura of the spinal canal, and can be a clinical challenge to diagnose due to the insidious presentation, with symptoms ranging from asymptomatic to non-specific head or neck pain, or neurological deficits.The etiology of spontaneous spinal epidural hematomas remains largely unknown, although there are many predisposing factors, including vascular malformation, anticoagulation therapy, trauma, iatrogenic manipulations, and hypertension.The differential diagnosis to spinal epidural hematomas are several, e.g., meningitis, migraine, subarachnoid or intracranial hemorrhage, pituitary apoplexy, venous sinus thrombosis, and thrombosis, and radiological examination is key to diagnose and map the distribution of the hemorrhage.