Severe Local Pain Research Articles

Kyphoplasty: 2 years of experience in a neurosurgery department

Background Kyphoplasty is a new technique to treat collapsed vertebral body (VB) fractures. The technique is very effective for achieving rapid pain relief, restoring bone height, and consequent vertebral realignment, and thus stabilization of the vertebra. Methods We reviewed 57 patients with vertebral compression fractures. All patients were neurologically intact and presented with severe low back pain or localized pain over the thoracolumbar region. Indications for kyphoplasty were osteoporotic and traumatic compression fractures, osteolytic tumor metastases, and aggressive hemangiomas without spinal canal compression. Results In 57 patients, 77 levels were treated. Follow-up was 6.5 months. Patients were evaluated with a visual analog scale (VAS) preoperatively and postoperatively. The mean preoperative VAS score was 91.08 for pain, whereas the mean postoperative VAS score was 11.22. Percentage of mean pain relief was 87.9% during the first 6 months of follow-up. We achieved a 43.6% improvement in the height of the compressed VB and 6.3° of improvement in the kyphotic angle. No serious complications occurred. Mean hospital stay was 24 hours. Conclusions Kyphoplasty carries significantly less morbidity than vertebroplasty or open surgery. Risk for embolization is low. Normal kyphotic angle can be restored or improved by this technique. In the hands of experienced surgeons, kyphoplasty is a safe and a minimally invasive technique for patients with neoplastic, traumatic, or osteoporotic lesions of the vertebra or sacrum.

Long-Term Follow-Up of 5,930 Unrelated Volunteers Donating Bone Marrow or Peripheral Blood Stem Cells.

More than 1,1 million donors are registered in the DKMS Deutsche Knochenmarkspenderdatei donor center. Since the start of the program, 5,930 have donated bone marrow or peripheral blood stem cells. These donors were included in a follow up program with questionnaires and blood cell counts 1, 6, and 12 months, and thereafter annually. Non responding donors were interviewed via a telephone call which enables us to have a follow-up of all donors. The age range at harvest was 18 to 60 years (median 32.4 years). The cumulative observation years were 13,350 years for 2,644 bone marrow donors and 7,980 years for 3,286 peripheral blood stem cell donors. No severe immediate complications occurred during the harvests. Seven out of 2,644 bone marrow donors (0.3%) suffered from long lasting severe local pain. Three of them were hospitalized within 6 weeks after donation with hematoma, local infection or severe local pain. One donor of the peripheral blood stem cell group suffered from severe hyperthyroidism 14 days after donation. In this donor, euthyroidism was documented at the day of leukapheresis. Antibodies to thyroid peroxidase were already detectable in retrospectively analyzed cryopreserved samples from these time points. TSH receptor stimulating immunoglobulin appeared only after harvest accompanied by symptoms of hyperthyroidism. Rheumatoid arthritis was diagnosed in 2 peripheral blood stem cell donors (interval from harvest: 0 days and 1 year) and joint complaints were addressed by additional 4 donors. Vascular events were seen in 4 peripheral blood stem cell donors (cerebral ischemia in 3 donors 3 months, 1 year and 2.5 years after donation; myocardial infarction in a 58 years old male donor 2 years after donation) and in one bone marrow donor (Brown-Séquard-syndrome 4 years after harvest). Four donors of the bone marrow group and 5 donors of the peripheral blood stem cell group developed malignancies during the follow-up observation. Four donors of the bone marrow group died 1 year to 8 years after donation (sudden death, car accident, suicide, and unknown). In unrelated donors, bone marrow harvests and peripheral blood stem cell donations are safe procedures in specialized collection centers. Even in a large donor center as DKMS, the numbers of adverse events in the follow up period are small. The documentation of diseases early after harvest (autoimmune diseases, thromboembolic events etc.) needs a careful follow-up. A case-controlled study with sex-, age- and HLA-matched volunteers within the donor pool will therefore be initiated by DKMS.

Necrotizing Soft Tissue Infections: Improved Outcomes with Modern Care

The outcome of necrotizing soft tissue infections (NSTI) remains unchanged despite advances in care. Reasons cited are changing patterns of causative factors, delays in diagnosis, and inadequate antibiotic coverage and surgical treatment. To document outcomes of NSTI after aggressive management and to identify risk factors of mortality and prolonged hospital stay, we reviewed all our patients with NSTI admitted from January 2000 to January 2002. Causative factors, comorbid conditions, site of NSTI, physiologic parameters, symptoms, diagnostic tests, therapeutic interventions, and outcomes were analyzed. Patients were treated aggressively with antibiotics, admission to ICU, and frequent surgical debridements. Of 46 patients identified, 28 (61%) were admitted in ICU, and eight (17%) died. The patients who died had higher admission white blood cell counts (46 +/- 22 vs 22 +/- 10 x 10(3)/mm3, P = 0.01), higher admission pain score (8 +/- 1 vs 5 +/- 3, P = 0.02), longer intervals from admission to antibiotic administration (16 +/- 20 vs 6 +/- 12 hours, P = 0.02), and fewer surgical debridements (2.6 +/- 1.1 vs 3.6 +/- 1.7, P = 0.04). No independent risk factors of mortality or ICU admission were identified. We concluded that severe local pain and a significantly elevated white blood cell count on admission should alert the physician to the presence of severe infection and prompt the initiation of expeditious aggressive treatment.

Reconstruction of the Laminar Roof With Miniplates for a Posterior Approach in Intraspinal Surgery: Technical Considerations and Critical Evaluation of Follow-up Results

A retrospective clinical follow-up study of patients who underwent intraspinal surgery with reconstruction of the laminar roof using titanium miniplates. To evaluate the surgical technique of laminar roof reconstruction and to analyze follow-up results with regard to bony healing of the laminae and the development of spinal deformities. The reconstruction of the laminar roof was initially proposed to overcome adverse effects associated with extensive cervical laminectomy in children. Because technical evolutions such as the use of an air drill and miniplates have facilitated the procedure, it has gained more widespread use as a posterior approach for intraspinal surgery. Thus, with a sufficient number of patients treated and a longer period of follow up, it seems reasonable to critically evaluate the technique and its suitability as a standard approach for intraspinal surgery. The surgical procedures of 79 patient who underwent intraspinal surgery with osteotomy and reconstruction of a total of 323 spinal laminae using an air drill and miniplates were analyzed. In 59 patients, data of a complete clinical and radiologic follow-up examination were evaluated. Plain radiographs and computed tomography scans were analyzed for bony healing of the laminae and spinal alignment. Minor complications such as cerebrospinal fluid collections and disturbed wound healing occurred within normal ranges. The was no case of dural, nerve root, or spinal cord injury attributable to laminotomy or laminar reconstruction. Eight (14.3%) patients complained of moderate to severe local pain at the time of follow-up examination and 8 patients stated impaired mobility of their spine at the surgical site. Bony healing was confirmed radiologically in 86.1% of the laminae. In 12 patients, a preexisting spinal deformity worsened after surgery and five patients demonstrated a new spinal malalignment. No patient required additional surgery because of progressive spinal deformity. Intramedullary location of the lesion and cervical location of surgery were significantly associated with the development of spinal malalignment, whereas incomplete bony healing of the laminae was not. The reconstruction of the laminar roof using the technique described is safe, well suitable to serve as a standard posterior approach to intraspinal pathologies, and offers distinct advantages over laminectomy. However, some patients, particularly those with intramedullary cervical lesions, could develop spinal malalignment after surgery despite reconstruction of the laminar roof and sufficient bony healing of the laminae.

Safety profile of recombinant canarypox HIV vaccines

Attenuated poxviruses have been developed for use as candidate vaccine vectors. ALVAC, a strain of the Avipoxvirus canarypox, has been extensively evaluated as a vector for vaccines against the human immunodeficiency virus type 1 (HIV-1). This report presents the safety and reactogenicity data derived from 11 multicenter, randomized controlled trials of ALVAC-HIV vaccines conducted by the HIV Vaccine Trials Network (HVTN) and its predecessor, the AIDS Vaccine Evaluation Group (AVEG). Five different ALVAC vaccine constructs were tested among 1497 volunteers. Reactogenicity was similar for different ALVAC constructs. Local reactions of any grade to ALVAC vaccines were common. However, fewer than 2% of vaccinees had severe local responses, and less than 1% experienced severe local pain or tenderness. Systemic responses were mild and transient. As combination vaccine regimens are in common use, we also evaluated side effects of ALVAC vectors given in combination with a recombinant subunit protein. No significant differences were noted in the reactogenicity of ALVAC given with or without a recombinant envelope subunit vaccine. Black, non-Hispanic and male recipients of ALVAC-HIV reported less pain following vaccination than White, non-Hispanics and females, respectively. ALVAC-HIV vaccines are well tolerated at tested doses. The reactogenicity profiles are comparable to those reported for existing vaccines licensed for use among adults. Reactogenicity does not appear to be related to the number or type of inserted genes, and did not vary between different ALVAC constructs.

Soft-tissue infection: necrotizing fasciitis.

Necrotizing fasciitis (NF) is a potentially fatal infection of the skin and soft tissue. The early presentation may first appear as cellulitis. The skin stays intact in the early stages of NF; this leads to a deceptive benign appearance. The skin typically appears red, hot and exquisitely tender. Blisters may or may not be present. Severe local pain, which is out of proportion to the size and type of wound, is a hallmark sign seen in NF. Recognition of the signs and symptoms, as well as timely diagnosis and treatment of this condition is imperative. This is necessary in order to assist in preventing widespread tissue destruction, and enhance favorable patient outcomes. The purpose of this paper is to increase the knowledge and understanding of NF and to discuss the nurses' role in minimizing unfavorable outcomes.

Clinical and in vitro evidence for the efficacy of Australian red-back spider ( Latrodectus hasselti) antivenom in the treatment of envenomation by a Cupboard spider ( Steatoda grossa)

We report the case of a 22-year-old female who was bitten on the shoulder by a spider subsequently identified as a female Cupboard spider ( Steatoda grossa). She developed nausea, vomiting, and severe local and regional pain, similar to that seen in latrodectism. Symptoms were treated successfully with red-back spider antivenom (RBSAV). We also present in vitro data, which supports this clinical observation, and suggests that S. grossa venom is immunogenically reactive with both RBSAV and latrotoxin (LTx)-specific antibodies by Western blotting. Moreover, the effects of S. grossa venom on the isolated chick biventer cervicis nerve–muscle preparation are dose-dependent and similar to those seen with Latrodectus spp. venoms. S. grossa venom produced a sustained muscle contracture which could be prevented by pre-incubation of venom with RBSAV. Venom effects could also be reversed by the addition of antivenom after application of venom to the preparation. Although severe envenomation is uncommon following the bite of Steatoda spp. it may resemble latrodectism. These results indicate that RBSAV is likely to be effective in reversing symptoms of envenomation and should be considered in the treatment of patients with distressing or persisting symptoms.

Necrotizing fasciitis: a 10-year retrospective study of cases in a single university hospital in Oman

Objective: (1) To study the clinical profile of all cases of necrotizing fasciitis (NF) diagnosed in a university hospital in Oman. (2) To evolve a strategy for early diagnosis. Patients and Methods: The inpatient records of the Sultan Qaboos University hospital from 1990-99 were searched for the words ‘fasciitis’, ‘necrosis’ or ‘gangrene’ and cases of NF (defined as a soft tissue infection characterized by widespread necrosis of the subcutaneous tissues cofirmed at surgery or pathology or both) were selected and analyzed. Cases with necrosis due to other obvious causes were excluded. Results: Of the seven cases of NF (hospital incidence-8.4/10 5), there were three post-operative, three spontaneous and one post-traumatic. Sites involved: upper limb (1), lower limb (2), abdomen (2), gluteal (1), and breasts (1). The median age was 50 years (range 21–85) and the male:female ratio was 4:3. All patients had local pain out of proportion to the signs and six had fever. Hypotension, liver or kidney dysfunction or coagulopathy were seen in four and a drop in haemoglobin was seen in six. In none was NF even considered by the referring or admitting physician, diagnosis being delayed by 2–10 days. In four cases a diagnostic incision under local anesthesia revealed the correct diagnosis. At surgery, extensive fascial and fat necrosis were seen in all, but only two had myonecrosis. The commonest isolate was β-hemolytic group D streptococcus (4/7). Blood and tissue were positive for β-hemolytic group A streptococci in one fatal case. Mean hospital stay was 54.5 days (11–134), mean surgical procedures were 2.3 per case, two required ICU admission with one death. Conclusion: NF is a rare but serious bacterial disease that is often incorrectly diagnosed. Unexplained severe local pain, deep tenderness without impressive local signs, fall in haemoglobin, organ system dysfunction and constitutional upsets were regular features. A high index of suspicion and immediate direct inspection of the fascia facilitates an early diagnosis.

A case ascertainment study of septic discitis: clinical, microbiological and radiological features.

We studied the spectrum of septic discitis presenting to two busy district general hospitals over 2.5 years (November 1996 to April 1999), surveying the case notes of all patients attending Royal Bournemouth and Poole Hospitals with probable septic discitis on magnetic resonance imaging (MRI). Twenty-two cases of septic discitis were identified, suggesting an annual incidence of 2/100 000/year. Seventy-three percent of patients were aged > or =65 years. In 91% of patients, back pain was the presenting symptom, with neurological signs evident in 45% of patients. Fever >37.5 degrees C was present in 68% of patients, and a marked elevation of erythrocyte sedimentation rate (ESR) in 91%. Diagnosis was originally by MRI in 86% of patients, with plain radiographs not diagnostic of discitis in the early stages of the infection. Staphylococcus aureus was the commonest pathogen (41%), but in 18% of patients, no organism was identified. The major predisposing factors to septic discitis were invasive procedures (41%), underlying cancer (25%) and diabetes (18%). Pre-existing degenerative spinal disease was found in 50% of patients. Four patients whose causative organism was not isolated had a poorer outcome: one death and three with increased morbidity. Our estimated incidence rate (2/100 000/year) is higher than that in previous studies and may be due to a higher detection rate with MRI and/or a genuine increase in the number of cases. Septic discitis should be considered in any patient who has severe localized pain at any spinal level, especially if accompanied by fever and elevated ESR, or in the immunosuppressed.

Positive effect of regional analgesia (RA) in terminal stage paediatric chondrosarcoma: a case report and the review of the literature

A 10-year-old girl was treated for progressive left pelvic chondrosarcoma and severe local pain radiating to the ipsilateral lower extremity. Despite high doses of opioids, pain was poorly controlled and treatment resulted in urine retention and constipation. Positive effect on pain (143 out of 181 days) was obtained by regional analgesia. Continuous lumbar epidural opioid infusion led to pain relief and disappearance of symptoms. Port-catheter dysfunction necessitated a change of epidural catheter and the patient was treated that with morphine, bupivacaine and clonidine plus clonazepam which resulted in relief of constipation and restoration of urinary function. The patient subsequently developed an abscess required or subarachoid infusion (morphine associated with clonazepam, clomipramine and corticosteroids). Later bilateral controlateral cordotomy was performed due to absence of analgesia and the patient subsequently died of tumour progression.

Pseudoappendicitis preceding infectious mononucleosis

In patients with infectious mononucleosis, abdominal pain is usually attributed to visceral enlargement. A teenage girl with symptoms of appendicitis was found at laparotomy to have mesenteric adenitis. Postoperatively, she developed classic features of Epstein-Barr virus (EBV)-induced mononucleosis. The lymphoproliferation characteristic of EBV infection can cause severe localized abdominal pain that predates the onset of mononucleosis.

Pseudoappendicitis preceding infectious mononucleosis

In patients with infectious mononucleosis, abdominal pain is usually attributed to visceral enlargement. A teenage girl with symptoms of appendicitis was found at laparotomy to have mesenteric adenitis. Postoperatively, she developed classic features of Epstein-Barr virus (EBV)-induced mononucleosis. The lymphoproliferation characteristic of EBV infection can cause severe localized abdominal pain that predates the onset of mononucleosis.

Platypus Venom and Envenomation.

Curiosity and controversy have surrounded the function of the crural system of the platypus since its discovery in the late 18th century. Early work on the venom confused rather than clarified the biological significance of the crural system. Many experiments gave conflicting results, especially concerning the coagulation effects of intravenous injections of venom extracts, although consistent observations were made of general vasodilation following intravenous injection into rabbits. More recent studies have shown that crural (venom) gland activity is seasonal and in synchrony with the breeding season. Secretion from the crural glands shows proteolytic activity and contains at least three major proteins, one of which has hyaluronidase activity. Subcutaneous injection of venom produced mild toxic effects whereas intravenous doses (75-90mg protein/kg) in mice were lethal. Whole venom induced local oedema after subplantar injection in rats and a 4.2kD peptide isolated from the venom caused relaxation of rat uterus in vitro. At least 16 incidents of envenomation by the platypus have been recorded in humans but no fatalities have been reported. In most human cases, envenomation resulted in immediate and severe local pain and oedema, sometimes associated with nausea, cold sweats, dull gastric pain and vomiting, hyperaesthesia and swelling of the axillary lymph nodes. Significant functional impairment of the upper limb for some weeks or months has been observed. Various treatments have been used to alleviate the symptoms of envenomation with differing successes. Envenomation has also been recorded in platypuses and dogs. The effects of these envenomations will be discussed.

Results of percutaneous implantation of coated vascular prostheses in long-distance femoropopliteal occlusions

Evaluation of primary patency rate, complications and midterm follow-up after implantation of endoprostheses in femoropopliteal occlusions. 25 patients suffering from femoropopliteal occlusion (average length 7 cm) underwent percutaneous femoropopliteal endoprosthesis treatment. A total of 34 endoprostheses were implanted. Clinical and Doppler follow-up was performed after 1, 3, 6 and 9 months. Mean follow-up is 6 months. Percutaneous placement of endoprostheses was successful primarily in 24/25 patients. In one patient an early occlusion of the endoprosthesis occurred, caused by an embolic complication. Primary patency was 64% after 6 months and secondary patency rate was 71%. Severe local pain at the application site and fever was observed in 40% of the patients. The occlusion rate of 36% after 6 months is high. Long-term follow-up must be awaited before a general recommendation can be made. The cause of the local pain and fever in the early postinterventional period remains unclear.

Vasodilators: Scorpion envenoming and the heart (an Indian experience)

Our aim was to assess clinically whether there was any benefit in adding a single dose of sublingual nifedipine (a slow calcium channel blocker) to prazosin in the management of the cardiovascular manifestations of envenoming by the Indian red scorpion ( Mesobuthus tamulus). A total of 163 patients stung by this species was admitted to hospital at Mahad between January 1991 and October 1993. Cardiovascular abnormalities were hypertension (59), of whom 42 had bradycardia and 17 had tachycardia; pulmonary oedema (14), of whom eight had hypertension and six hypotension; supraventricular tachycardia (eight), of whom three had hypotension and one died. Of the remaining patients, 78 demonstrated severe excruciating local pain at the site of sting but had no systemic involvement. Nineteen patients with hypertension and tachycardia were given a single dose of sublingual nifedipine plus prazosin on admission, then prazosin alone repeated 6 hourly. Five patients with massive life-threatening pulmonary oedema recovered after being given intravenous sodium nitroprusside. Prazosin alone helped to alleviate cardiovascular manifestations in the remaining 52 victims. One patient was admitted in a deep coma, 12 hr after the sting, and died. Eight victims whose blood pressure had been controlled in hospital by nifedipine plus prazosin developed acute pulmonary oedema necessitating additional doses of prazosin for recovery. Fifty-two victims treated with prazosin alone did not develop pulmonary oedema and the drug appeared to hasten the recovery. In the presence of high blood pressure, tachycardia, a murmur and impending myocardial failure, nifedipine appeared to contribute to cardiopulmonary instability and to augment myocardial oxygen consumption. In this situation calcium channel blockers should probably be avoided.

Tolerance and safety of orally administered antimicrobial agents: An important factor in the selection of drug therapy

Efficacy and safety are two key factors in the selection of orally administered antimicrobial agents. This paper reviews the safety profile of oral cephalosporins, macrolides, and fluoroquinolones. Oral cephalosporins and the macrolides are among the safest classes of antimicrobial agents. The most common adverse events associated with oral cephalosporins are hypersensitivity reactions, which occur in 0.7% to 10% of patients. Approximately 5% to 10% of patients with hypersensitivity reactions to penicillin have cross-reactions (usually rash) with oral cephalosporin therapy. There do not appear to be major differences in toxicity among individual oral cephalosporins. The most common adverse event associated with the macrolides is gastrointestinal distress, particularly erythromycin at dosages >4 gm/day. Erythromycin should not be administered intramuscularly because it causes severe local pain. Drug interactions are among the most serious adverse events associated with macrolide therapy. These drugs may inhibit other drugs such as theophylline and carbamazepine, which are metabolized through the liver cytochrome P 450 pathway. If administered concomitantly, serum concentrations of these agents should be monitored closely. Erythromycin inhibits cyclosporin metabolism. Fluoroquinolones also have an excellent safety profile. The most common adverse events are gastrointestinal disturbances, which occur in 2% to 8% of patients. Approximately 1% to 4% of patients experience central nervous system complications. Fluoroquinolones have been shown to cause cartilage erosion in young animals and are not approved for pediatric use in the United States. Some drug interactions may also occur with fluoroquinolone use. In summary, the oral cephalosporins, macrolides, and fluoroquinolones are remarkably safe and effective antimicrobial agents.

Non-venomous snake bite and snake bite without envenoming in a Brazilian teaching hospital. Analysis of 91 cases.

A retrospective survey of 473 cases of snake bite admitted to a Brazilian teaching hospital from 1984 to 1990 revealed 91 cases of bite without envenoming and/or caused by non-venomous snakes. In 17 of these cases the snake was identified, and one patient was bitten by a snake-like reptile (Amphisbaena mertensii). In 43 cases diagnosis was made on clinical grounds (fang marks in the absence of signs of envenoming). The other 30 cases were of patients who complained of being bitten but who did not show any sign of envenoming or fang mark. Most cases occurred in men (66;73%), in the 10-19 years age group (26;29%), in the lower limbs (51/74;69%), between 6 A. M. and 2 P.M. (49;61%) and in the month of April (16;18%). One patient bitten by Philodryas olfersii developed severe local pain, swelling and redness at the site of the bite, with normal clotting time. The patient bitten by Drymarcon corais was misdiagnosed as being bitten by a snake of the genus Bothrops, was given the specific antivenom, and developed anaphylaxis. One patient bitten by Sibynomorphus mikanii presented prolonged clotting time, and was also given antivenom as a case of Bothrops bite. Correct identification of venomous snakes by physicians is necessary to provide correct treatment to victims of snake bite, avoiding unnecessary distress to the patient, and overprescription of antivenom, which may eventually cause severe untoward effects.

Didelphic uterus and unilaterally imperforate double vagina as an unusual presentation of right lower-quadrant abdominal pain

Imperforate hymen should be considered in girls of menarcheal age with a history of amenorrhea and vague abdominal discomfort, particularly if associated with symptoms of urinary obstruction or constipation. Patients may present with severe dysmenorrhea and localized pain mimicking appendicitis if hematocolpometra is due to unilaterally imperforate hymen with duplicate vagina and didelphic uterus. Although this condition is exceedingly rare, the case presented stresses the importance of a careful history and physical examination of an adolescent girl presenting with symptoms of abdominal pain associated with menstruation.

Rediscovery and redefinition of Malcolm Smith's Trimeresurus kanburiensis in Thailand, with a report of envenoming

Three specimens of an apparently rare pit viper, Trimeresurus kanburiensis, previously known only from the holotype collected in 1928, were found near Kanchanaburi in western Thailand. One of the snakes had bitten a young woman on the foot. She experienced severe local pain, swelling that involved the whole of the bitten limb and beyond, local bruising, recurrent shock, peripheral leucocytosis and a mild coagulopathy, but she recovered despite the lack of specific treatment. The severity of envenoming augurs ill for a young or debilitated patient bitten by this species. During the last 20 years, the name T. kanburiensis has been used incorrectly for the medically more important species, T. purpureomaculatus. Conversely, the name T. purpureomaculatus has been misapplied to specimens of a species of viper from southern Thailand which we consider very similar to T. kanburiensis, but for which a new specific name, ‘ T. venustus’, has been suggested recently. The rediscovery and redefinition of T. kanburiensis should prevent further confusion.

Spinal Epidural Hemorrhage Three Cases Report and Literature Review

Spinal epidure hemorrhage is rare. It is often misdiagnosed and mistreated, and may result in severe paraplegia or death. Abort half of the cases reported in the literature had identifiable causes. Among these, trauma and anticoagulant therapy were most frequently encountered. The others were known as spontaneous spinal epidural hemorrhage. We report here 3 cases treated in NTUH. Their symptoms included sudden onset of severe localized back pain and flaccid paralysis of lower extremities which progressed within minutes to days. In case 1, early spinal decompression minimized the possible neurological sequelae. In case 2, hematoma occurred in the lower thoracic spine. Pain in the early stage was not differenciated carefully from acute abdomen. Diagnosis was made in case 3 when flaccid paralysis developed completely. Unlike that occurs in the skull, epidural hemorrhage in the spine is always a surgical emergency. It is important to differentiate from other causes of spinal cord injury, and to make early diagnosis and management.