Case Of Spinal Epidural Hematoma Research Articles

Spinal cord injury and spinal fracture in patients with ankylosing spondylitis

BackgroundSpinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS.MethodsThis retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture.ResultsOf the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P < 0.001) and more cases of spinal epidural hematoma (SEH; 21.7% vs. 2.2%; P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004).ConclusionsPatients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3–C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.

Cauda equina syndrome due to Factor Xa inhibitor (Rivaroxaban): Case report and review of literature

Background: Factor Xa inhibitors are widely used by the physicians to reduce the incidence of thrombosis in order to protect the cardiovascular function. Although complications of bleeding and spontaneous gastrointestinal sources have been reported before, there are very sporadic cases of spinal epidural haematoma causing neurological compromise. Case presentation: We report a case of spontaneous spinal epidural haematoma (SSEH) in an 85-year-old female patient treated with Rivaroxaban, a new agent to prevent the incidence of thrombo-embolic events. Anticoagulant therapy is a recognised risk factor in the development of spontaneous bleeding and haematomas. The patient presented to the emergency department with sudden onset of severe back pain in the lumbar spine associated with paraplegia in the lower limbs. Magnetic resonance imaging (MRI) of the spine demonstrated a SSEH from T12 to L5 affecting the cauda equina. Rivaroxaban was discontinued and the patient was monitored as an inpatient. There was gradual improvement in the symptoms of the lower limbs. Conclusion: This rare condition of incomplete cauda equina syndrome due to Rivaroxaban therapy has not been reported previously. Clinicians must have a high index of suspicion in patients on regular anti-coagulation regimen.

Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain.

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).

Etiopathogenesis of Traumatic Spinal Epidural Hematoma.

Spinal epidural hematoma (SEH) is a rare cause of nerve root or cord compression; its pathogenesis is not always clearly recognizable. The aim of this paper was to investigate possible etiopathological factors in a consecutive series of patients affected by traumatic SEH treated at our institution. Seven patients with neurologic impairment due to traumatic SEH were retrospectively analyzed after diagnosis and surgical treatment. Thoracic localization was found in 5 cases, and lumbar and cervical localization were found in 1 patient each. One patient was affected by ankylosing spondylitis and one by diffuse idiopathic skeletal hyperostosis. SEH was associated with spine fractures in 6 cases. Only 2 cases of traumatic SEH resulted from high-energy trauma. All patients underwent surgical decompression within 24 hours after admittance to the hospital. Three patients recovered completely, 3 remained paraplegic, and 1 remained monoplegic. Several concomitant conditions are suggested to be predisposing factors for the development of SEH, although its inherent mechanism is still unknown. Two patients in the present series were affected by rheumatologic disorders, confirming the elevated incidence of hematomas in such patients compared to the normal population. Three very unusual cases of SEH occurred in senile patients affected by osteoporotic fractures. Early diagnosis and urgent decompression of the hematoma remain mandatory.

Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low–Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma

(Anesth Analg. 2017;125(1):223–231) National guidelines stipulate that pregnant women at risk for venous thromboembolism, such as women undergoing cesarean delivery (4-fold increased risk compared with vaginal delivery), receive thromboprophylaxis via mechanical means, low–molecular-weight heparin (LMWH) and or unfractionated heparins (UFHs). Because of a limited number of studies addressing the boundaries for safe use of neuraxial anesthesia in obstetric patients receiving thromboprophylaxis, or anticoagulated patients, the authors of the present review report on all cases of spinal epidural hematoma (SEH) after neuraxial blockade in this population of obstetric patients.

Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low-Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma.

Venous thromboembolism remains a major source of morbidity and mortality in obstetrics with an incidence of 29.8/100,000 vaginal delivery hospitalizations; cesarean delivery confers a 4-fold increased risk of thromboembolism when compared with vaginal delivery. Revised national guidelines now stipulate that the majority of women delivering via cesarean and women at risk for ante- or postpartum venous thromboembolism receive mechanical or pharmacological thromboprophylaxis. This practice change has important implications for obstetric anesthesiologists concerned about the risk of spinal epidural hematoma (SEH) among anticoagulated women receiving neuraxial anesthesia. We conducted a systematic review of published English language studies (1952-2016) and of the US Anesthesia Closed Claims Project Database (1990-2013) to identify cases of SEH associated with neuraxial anesthesia and thromboprophylaxis. We also report on SEH in obstetric patients receiving thromboprophylaxis and neuraxial anesthesia without adherence to the American Society of Regional Anesthesia (ASRA) recommendations. In our review, we initially identified 736 publications of which 10 met inclusion criteria; these were combined with the 5 cases of SEH identified in 546 obstetric Anesthesia Closed Claims reviews. None of these publications revealed SEH associated with neuraxial anesthesia and thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin in obstetric patients. Based on data from 6 reports, 28 parturients had their neuraxial blockade before the minimum ASRA recommended time interval between the last anticoagulant dose and the neuraxial procedure. Based on data from 2 reports, 52 parturients received neuraxial anesthesia without their low-molecular-weight heparin dose being discontinued during the intrapartum period. Although the very low level of evidence and high heterogeneity in these reports make it difficult to draw quantitative conclusions from this systematic review, it is encouraging that this comprehensive search did not identify a single case of SEH in an obstetric patient receiving thromboprophylaxis and neuraxial anesthesia. Analysis of large-scale registries (eg, the Anesthesia Incident Reporting System of the Anesthesia Quality Institute) with more granular clinical and pharmacological data is needed to assess the impact of these practice changes on obstetric SEH incidence. In the interim, optimal care of obstetric patients depends on multidisciplinary planning of anticoagulation dosing to facilitate neuraxial anesthesia and thoughtful weighing of the relative risks and benefits of providing versus withholding neuraxial in favor of general anesthesia.

Clinical Manifestations of Spinal Epidural Hematoma-Stroke Mimic and Pitfalls in Diagnosis

Clinical manifestations of spinal epidural hematoma are presented, and the cases mimicking acute ischemic stroke have been reviewed from the literature. Many reports described the cases of spinal epidural hematoma with acute hemiparesis mimicking ischemic stroke in which intravenous thrombolytic treatment with recombinant tissue plasminogen activator was considered. A correct diagnosis of acute ischemic stroke must be made within 4.5 hours from the onset of symptoms, a relatively short window period. A spinal epidural hematoma is a potentially important stroke mimic in a wide variety of conditions that mimic a stroke. The literature review and discussion will emphasize allowing the distinction between these hemiparetic presentation of spinal epidural hematoma and acute ischemic stroke. A spinal epidural hematoma should be considered in the differential diagnosis of patients with acute onset of hemiparesis when associated with neck pain and signs of Horner's syndrome and Brown-Sēquard syndrome.

術後硬膜外カテーテル抜去時に生じた硬膜外血腫の1例

術後硬膜外カテーテル抜去時に生じた硬膜外血腫の1例

Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture.

We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case.

Epidural hematoma associated with L2 Chance fracture in a long lumbar posterior fused spine patient: A case report and literature review

Introduction: Several studies have reported that minor trauma could cause a fracture of the ankylosed spine, which easily becomes unstable due to the inflexibility of the fused spine and long lever arm. Delayed diagnosis of spinal epidural hematoma (SEH) may result in increased risk of neurological injury and poor prognosis. Purpose: To highlight the risk of lumbar spine Chance fracture associated with symptomatic SEH in a patient with long lumbar spine fusion (LSF). Methods: The clinical findings, radiographic appearance, and surgical treatment of a SEH associated with L2 Chance fracture in LSF are described. Results: A 55-year-old male patient, injured after falling from a 2.5 m tree, presented with severe back pain. On plain radiographs and computed tomography (CT) images, anterolateral osteophytes and fused lumbar vertebrae (L1－L5), in addition to an L2 Chance fracture, were noted. Patient was initially treated with bed rest followed by placement in a body cast due to improved clinical neurological deficits. Three days later, he presented with incomplete paraplegia of his lower limbs. Magnetic resonance imaging (MRI) images showed a SEH compressing the dura mater over L1－L3 area. The patient was successfully treated by L2 decompression and posterior fixation surgery using pedicle screws and rods over L1－L4. Postoperatively, there was rapid progressive improvement of motor and sensory function. Conclusions: A unique case of SEH complicating a L2 Chance fracture in LSH is presented. LSH is a risk factor for fracture and subsequent development of SEH. A high index of suspicion of SEH is necessary in such a case, particularly with early neurological deficits. Imaging studies including MRI and CT scans should be reviewed carefully to rule out any fracture or SEH.

Chronic Spinal Epidural Hematoma in an Adult

Spinal epidural hematoma (SEH) causing neurological deficit is a rare clinical entity. It may have either traumatic origin or it may occur spontaneously. Majority of the reported cases of SEH had nontraumatic causes and most of them were in the acute stage. Early chronic traumatic SEH in an adult is very rare and its prompt diagnosis with magnetic resonance imaging (MRI) is crucial for the accurate management of the patient. Our case was 56 year-old man presented at our neurosurgery clinic with a complaint of progressive burning pain, weakness, paresthesia over the left leg and hypoesthesia over the pelvic region. In this report, we presented a postraumatic lumbar SEH which is a unique presentation of chronic traumatic SEH because of long time interval between the trauma and beginning of the symptoms.

English

As far as operative indications for spinal epidural hematoma are concerned, symptoms and duration from onset are thought to be quite important. However, magnetic resonance imaging (MRI) intensity of the hematoma could be a key factor in determining the need for operative intervention. Here, we discuss two cases of spinal epidural hematoma. One was the operative case of a 71-year-old man who presented with left leg paresis. On the initial spinal MRI, a low-iso T1-weighted image (WI) showed a slight high-iso T2WI heterogenous intensity and a thick epidural mass that had compressed the spinal cord dorsolaterally from the C7 to T5 levels. The mass was diagnosed as a cervicothoracic epidural hematoma in the acute phase as coagulation seemed to be starting. Five hours after presentation, his symptoms evolved into complete paraplegia; therefore, decompression laminectomy and hematoma evacuation was performed. The other case was that of a 68-year-old woman with severe neck pain. The initial MRI demonstrated a T1WI iso, T2WI high homogenous intensity epidural mass from the C2 to T4 levels. A spinal epidural hematoma in the hyperacute phase was diagonesd. Conservative treatment was recommended, and her symptoms and hematoma almost disappeared within three days. When coagulation or organization of the hematoma has not started, its absorption might be expected at an early stage. MRI appearances, including hematoma intensity, combined with simultaneous clinical information might be very important for surgical decision making and predicting prognosis in cases of spinal epidural hematomas. Key words: Spinal epidural hematoma, MRI intensity, surgical decision making.

Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site

Case report. We report a case of spinal epidural hematoma (SEH) that appeared on the third postoperative day after lumbar spinal anesthesia, far from the needle puncture site. Possible mechanisms and etiological relation to patient's risk factors as well as diagnosis and management of SEH are briefly discussed. Asklepieion General Hospital of Voula, Athens, Greece. A 64-year-old woman underwent an uneventful total knee arthroplasty operation under a spinal anesthetic. A lumbar puncture was performed in the L2-L3 interspace, that was atraumatic and successful on the first attempt. The operation was uneventful. On the third postoperative day, the patient developed a SEH that expanded from C2 to T3 levels. She was presented with bilateral shoulder pain, muscle weakness of the upper extremities with normal sensation, followed by paraparesis. The magnetic resonance imaging (MRI) revealed a large vascular malformation, partially ruptured forming a hematoma compressing the spinal cord toward the vertebral bodies The patient was treated conservatively and full recovery was achieved. The possibility of SEH must be considered whenever neurological symptoms occur in the postoperative period, especially after a neuraxial blockade. The causes are multiple, a not-known lesion predisposing to bleeding and hematoma formation may preexist and the anesthetic technique can be directly or indirectly connected to this complication. MRI is the preferred diagnostic method.

Spinal Epidural Hematoma during Anticoagulant Therapy for Pulmonary Embolism: Postoperative Complications in a Patient with Lung Cancer

Spinal epidural hematoma (SEH) is rare but causes neurological disorders. Rapid diagnosis and treatment maximize neurological recovery. We present the case of SEH after lung cancer surgery under epidural and general anesthesia. A 64-year-old man underwent right upper lobectomy. Pulmonary embolism occurred on postoperative day 2. Anticoagulant therapy with fondaparinux and warfarin was started 2 hours after epidural catheter removal and he gradually recovered. On postoperative day 13, the level of prothrombin time-international normalized ratio reached 1.47 and fondaparinux administration was stopped. The next day, he developed back pain and paraplegia, and magnetic resonance imaging revealed a mass between Th4 and Th7 compressing the spinal cord. Emergency decompression laminectomy and hematoma evacuation were performed. After 2.5 months of rehabilitation, he regained almost all motor function and sensation. Late after epidural anesthesia, attention should be paid to possible SEH even though appropriate anticoagulant therapy had been initiated after epidural catheter removal.

Medicolegal Cases for Spinal Epidural Hematoma and Spinal Epidural Abscess

Spinal epidural hematoma and spinal epidural abscess are rare surgical emergencies resulting in significant neurologic deficits. Making the diagnosis for spinal epidural hematoma and spinal epidural abscess can be challenging; however, a delay in recognition and treatment can be devastating. The objective of this retrospective analysis study was to identify risk factors for an adverse outcome for the provider. The LexisNexis Academic legal search database was used to identify a total of 19 cases of spinal epidural hematoma and spinal epidural abscess filed against medical providers. Outcome data on trial verdicts, age, sex, initial site of injury, time to consultation, time to appropriate imaging studies, time to surgery, and whether a rectal examination was performed or not were recorded. The results demonstrated a significant association between time to surgery more than 48 hours and an unfavorable verdict for the provider. The degree of permanent neurologic impairment did not appear to affect the verdicts. Fifty-eight percent of the cases did not present with an initial deficit, including loss of bowel or bladder control. All medical professionals must maintain a high level of suspicion and act quickly. Physicians who are able to identify early clinical features, appropriately image, and treat within a 48 hour time frame have demonstrated a more favorable medicolegal outcome compared with their counterparts in filed lawsuits for spinal epidural hematoma and spinal epidural abscess cases.

Spontaneous spinal epidural hematoma during pregnancy: a rare obstetric emergency

Spontaneous spinal epidural hematoma is a rare obstetric emergency which warrants immediate management to prevent permanent neurological deficit. Only 12 cases have been reported in the literature so far [1], and most of them are located in the dorsal epidural space. Hematomas in ventral epidural space are rare because the posterior longitudinal ligament is tightly adhered to the anterior dura while the dorsal epidural space is filled with fat [2]. We present a case of spinal epidural hematoma in pregnancy, restricted to the ventral epidural space.

Chronic Traumatic Spinal Epidural Hematoma in a Child

Spinal epidural hematoma (SEH) can lead to progressive neurological deficits that are the result of spinal cord compression. Most of the reported cases of SEH had nontraumatic origins, and they were mainly in the acute stage. Traumatic SEH in a child is rare, and it is also difficult to diagnose because of the nonspecific pain and irritability of the child. We present here the first reported case of chronic traumatic SEH in a 3-yr-old boy. He was admitted with axillary pain and slowly progressive weakness after a fall that had occurred 4 wks before. On admission, he could not stand or hold a spoon. Magnetic resonance imaging revealed epidural hematomas from C5 to C7; these hematomas showed high signal intensity on the T1-weighted images and heterogeneous high-iso signal intensity on the T2-weighted images. After the surgical decompression, the patient showed a complete resolution of symptoms without any neurological sequelae. Our study suggests that a child with unexplained pain and motor weakness should undergo magnetic resonance imaging for making an early diagnosis. Chronic traumatic SEH in a child can be successfully treated by a surgical operation.

Conservative management of an acute spontaneous holocord epidural hemorrhage in a hemophiliac infant

Central nervous system hemorrhages are an uncommon but severe complication of hemophilia, occurring in only 2-8% of children with hemophilia. Less than 10% of these CNS hemorrhages are intraspinal. The authors report on their care of an infant with hemophilia A who presented with irritability, meningismus, and decreased spontaneous movement. These symptoms prompted imaging studies, which revealed a spinal epidural hematoma (SEH) extending from C-1 through the cauda equina. The boy was treated with factor replacement and close monitoring. Repeat radiographic imaging 14 days later demonstrated complete resolution, and the patient had returned to his normal baseline status. A literature review in the modern treatment era revealed 24 cases of SEH in children with hemophilia. Of these 24 cases, 11 underwent laminectomy and 13 received conservative treatment. All conservatively treated patients, 5 of whom had presented with weakness, experienced a full recovery. Of the 11 laminectomy patients, 10 presented with weakness and all but 3 experienced full neurological improvement. These 3 patients were notable for having previously undiagnosed hemophilia. An increased index of suspicion facilitates the essential management features of prompt diagnosis and correction of coagulopathies in children who present with SEHs. The authors apply a multidisciplinary approach involving a pediatric hematologist, neurosurgeon, and pediatric intensive care unit to ensure timely correction of the coagulation disorder, maintenance of adequate factor levels, and close hemodynamic and neurological monitoring. Observation with aggressive correction of coagulopathy is a reasonable treatment choice for hemophilic patients presenting with SEH and a stable neurological examination.

Experiments of five cases of spinal epidural hematoma

Experiments of five cases of spinal epidural hematoma

Chronic Back Pain Secondary to a Calcified Epidural Blood Patch

Chronic Back Pain Secondary to a Calcified Epidural Blood Patch