Spinal Hematoma Research Articles

Post-traumatic spinal hematoma in ankylosing spondylitis.

The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients. A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and ninemonths were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports. Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate. Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Is obesity asignificant risk factor of symptomatic spinal epidural hematoma after elective degenerative lumbar spine surgery?

The occurrence of symptomatic spinal epidural hematoma after spine surgery is arare, but serious major complication whose incidence usually requires urgent surgical intervention. Obesity is currently considered to be one of the most common metabolic diseases. Prospective analysis of patients who underwent surgical treatment of degenerative lumbar spine disease from January 2016 to February 2018 with one-year follow-up. All patients underwent decompression of spinal cord and nerve roots. This study was conducted to determine an association between the incidence of spinal epidural hematoma (SEDH) requiring surgical treatment and obesity/body mass index (BMI). In our study, data from 371 patients were assessed. SEDH requiring surgical intervention occurred totally in seven patients (1.89 %). An average BMI in patients with presence of SEDH was 30.67 kg/m2. Our work showed a statistically significant difference between BMI in patients with SEDH compared to patients without SEDH (p = 0.0044). This study also showed a significant difference in incidence of symptomatic SEDH in obese patients compared to non-obese patients (p=0.0158). In our study, we found out that obesity is a significant risk factor for the incidence of postoperative SEDH after degenerative lumbar spine surgery (Tab. 1, Fig. 2, Ref. 18).

Particularities of clinical onset and favorable evolution towards functional neurorehabilitation in a very large post-acenocoumarol overdose hematoma (C7-T10) ---a case report

Introduction: The incidence of spontaneous spinal epidural hematoma is relatively rare and it may cause a spinal cord injury possibly associated with related severe disabling conditions: sensory-motor impairments, back pain, neurogenic bladder and bowel. The MRI is the golden standard diagnostic examination in patients suspected of spinal epidural hematoma. Still, such a spontaneous condition can be, not-seldom, asymptomatic. Materials and methods: This paper presents the case of a 79-year-old male patient with permanent atrial fibrillation, treated with acenocoumarol, who was admitted, first in the General Surgery Clinic Division with rectal tenesmus and acute urinary retention and, subsequently developed a sudden onset of motor deficit, as presented in the body text. The patient was diagnosed with epidural hematoma (C7-T10) resulting in AIS/Frankel C paraplegia, with T10 neurological level. The positive and differential diagnoses concluded that the acenocoumarol overdose was the main etiopathogenic factor. Results: The patient—being promptly transferred to the Spinal Neurosurgical Clinic Division—received conservative treatment, followed by a neuro-muscular rehabilitation program achieved in our Neuro-Rehabilitation Clinic Division, with mainly favorable outcomes: at discharge he was able to walk independently on short distances. Conclusions: The clinical outcomes and quality of life of patients suffering from spinal epidural hematoma depend on the fast diagnosis and efficient acute neurosurgi-cal/conservative treatment, followed by an appropriate rehabilitation program, including with medium and long term medical follow-up. This clinical case has received the Teaching Emergency Hospital “Bagdasar-Arseni” Bioethics Committee approval No. 27/1935-25.02.2021.

Lumbar spinal epidural hematoma without vertebral fracture causing cauda equina syndrome

Spinal epidural hematoma (SEH) is a rare disease and may lead to spinal cord compression. It could be caused by trauma, including iatrogenic procedures such as spinal surgery or spinal anesthesia or by spontaneous events related to coagulopathy or arteriovenous malformation. Once SEH is suspected clinically and confirmed by image modalities, it should be emergently decompressed by surgical intervention. Prognosis depends on the rate of symptoms development, interval from symptom onset to surgery, level of spinal involvement, and degree of neurological deficits. Here, we report the case of a 79-year-old female who sustained a fall months before admission, presented with a 3-day history of back and bilateral lower limbs weakness. Radiography and magnetic resonance imaging demonstrated epidural hematomas at the level of T12 to L2 without associated vertebral fracture. An urgent decompressive laminectomy with blood clot removal was performed immediately. Postoperatively, her neurologic deficits improved significantly except for residual numbness.

A Bibliometric Analysis of the Most-Cited Articles on Craniospinal Epidural Hematoma.

To analyze the most-cited articles on cranial and spinal epidural hematomas (EDHs). A title-specific search was performed on the Scopus database using the term ?epidural hematoma? in June 2020, with no publication date restrictions. The top 100 most-cited articles were collected, reviewed, and analyzed. A total of 2165 articles were published on EDH from 1949 to 2020, and the top 100 most-cited ones were published between 1966 and 2014, receiving an average citation of 84.7 per paper. Most papers were published in Neurosurgery and Journal of Neurosurgery (JNS). 48% of the most-cited articles on EDH originated from the United States of America (USA). Notably, studies on spinal EDH represented 75% of the most-cited articles in our review. The most-cited article on EDH was published by Lawton et al. in 1995, receiving a total of 412 citations at an annual citation rate of 16.4%. This report identifies the most influential publications on EDH as well as the publications trends over the last 70 years. Recognition of the most impactful work is an important tool for clinicians and researchers as it can reflect the enormous changes in the clinical practice. This report can serve as a guide for developing evidence-based practices and identifying areas of research inadequacy.

Spontaneous spinal intramedullary hematoma in an infant: A rare entity and a diagnostic challenge

ABSTRACTIntroduction:Spontaneous spinal intramedullary hematoma is a rare cause of acute paraplegia in adults and is extremely uncommon in children. Very few cases with no apparent etiology (such as trauma, vascular lesions) have been reported in adults. We did not find any apparent cause for the hematoma in our patient and to the best of our knowledge, this is first case reported in infants.Case Report:We present the case of a 6-month-old female child admitted with acute-onset paraplegia, bladder bowel involvement, and no history of trauma or bleeding diathesis. The MRI showed an intramedullary mass extending from the D11-L1 level. The mass was excised and histopathology revealed it to be an organizing hematoma.Conclusion:Our case highlights that though it is a rare entity, there is a need for more awareness when dealing with children with sudden paraplegia, acute retention of urine, or neurological deficit. Early diagnosis and prompt surgery are crucial to achieve the best neurological outcome.

Neuraxial Hematoma Following Lumbar Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair

Cerebrospinal fluid drainage is recommended for spinal cord protection in open and endovascular thoracoabdominal aortic aneurysm (TAAA) repairs. We report a case of spinal hematoma following lumbar drain removal in a patient who underwent thoracic endovascular aortic repair for DeBakey type III aortic dissection. There is always a debate concerning placement of lumbar drain on the day of the procedure, postponement of the procedure if a traumatic tap is encountered and type of spinal catheter to avoid spinal hematoma in TAAA repairs. The practice of timing of catheter placement and choice of the type of catheter for lumbar varies with institutional practice, and there has been no recommendation regarding the safe practice for avoiding spinal hematoma. Avoiding traumatic tap during lumbar drain placement, team approach of an anesthesiologist, an interventional cardiologist, and a surgeon for decision-making to continue or postpone the procedure and timing of anticoagulation, meticulous neurological monitoring throughout the hospital stay of the patient can avoid spinal hematoma and sequelae.

Revisiting Intrathecal Dorsal Venous Patterns of the Spinal Cord at Thoracolumbar Level as Probable Factor for Post Lumbar Puncture Spinal Hematoma.

The spinal cord is drained by three interconnected venous systems. Among them the extrinsic venous system of the dorsal thoracolumbar region with its radicular communications is liable to get injured due to its anatomical position. With increasing case reports of post puncture hematomas, revisiting the intrathecal extrinsic venous system of spinal cord has become a necessity. In a tertiary teaching institution, 25 adult cadavers were dissected by standard dissection procedure and spinal cord was removed with meninges. The dorsal aspect was further dissected out and layers of meninges were removed carefully to expose the extrinsic venous system in the dorsal region. The specimens that showed engorged veins were further studied for their extent, pattern, presence of radicular veins, their level and route of exit. Five specimens showed variant dorsal venous pattern of the extrinsic system of veins in the thoracolumbar region. The main dorsal spinal vein was seen to be engorged, tortuous and more than 2mm with engorged radicular veins. Out of 8 engorged radicular veins observed, 6 exited through the dorsal nerve root foramen and 2 exited through a separate foramen. The variant anatomy of intrathecal extrinsic venous system with engorgement of the thoracolumbar region veins might get injured during lumbar puncture procedure. The exit of radicular veins and the dorsal nerve root through the same foramen also makes the veins susceptible to post procedural spinal hematomas.

Clinical course and outcomes of spontaneous spinal epidural hematoma

Clinical course and outcomes of spontaneous spinal epidural hematoma

Spontaneous spinal epidural hematoma: A rare cause of quadriparesis in a young person

Spontaneous spinal epidural hematoma (SSEH) is a rare condition with an incidence of 0.1 in 100,000 population. These are usually seen in the lumbar region in patients above 40 years and in the cervical and dorsal spine in younger patients. Posterior or dorsal epidural hematomas are more common than ventral hematomas. Patients present with sharp pain in the neck or back with or without neurological deficit. We present a case of a 20-year-old male who presented with quadriparesis and bowel and bladder incontinence for 5 days. No history of trauma or other aggravating factors were present. Magnetic resonance imaging revealed a posterior epidural hematoma with cord compression and edema. Patient underwent surgery and hematoma was evacuated. Patient symptoms improved gradually. Because of the severe preoperative neurological deficit and delay in surgery, patient had mild residual neurological deficit in the early post op period, which resolved over a period of two months

Letter to the Editor: Commentary on Recurrent Cervical Spontaneous Spinal Epidural Hematoma with Conservative Management: A Case Report (Korean J Neurotrauma 2021;17:186-191).

Letter to the Editor: Commentary on Recurrent Cervical Spontaneous Spinal Epidural Hematoma with Conservative Management: A Case Report (Korean J Neurotrauma 2021;17:186-191).

Spontaneous spinal epidural hemorrhage due to polycythemia vera

Spontaneous spinal epidural hematoma (SSEH) as an initial presentation of polycythemia vera (PV) is rare. It can present with the features ranging from simple back pain to complete paraplegia depending on the site of the spinal compression. Herein, we describe a case of undiagnosed PV presented as back pain with radiation to the chest wall in a 46-year-old male patient and subsequently diagnosed with spontaneous spinal epidural hemorrhage. To the best of our knowledge, only one case of spinal epidural hematoma-related PV has been reported so far. Emergent decompressive laminectomy was done within 10 h of initial presentation with excellent clinical outcome. Therefore, this condition must be promptly diagnosed and treated with decompression surgery to minimize the risk of neurological complication.

Peripheral nerve block (FLOS block) for intraoperative anesthesia in total knee arthroplasty: An observational study

Background: Peripheral nerve blocks (PNBs) are generally used to provide postoperative analgesia after total knee arthroplasty (TKA) and other lower extremity procedures; these blocks are used rarely for intraoperative anesthesia. We present here, the patients who underwent TKA under PNBs (FLOS Block). FLOS block is nothing but femoral, lateral cutaneous femoral nerve, obturator, and sciatic nerve block. Materials and Methods: A total of 41 patients participated in the study for TKA using PNB, FLOS block. All the patients received standardized anesthesia and analgesia upon hospitalization. Outcome evaluations included the visual analog scale (VAS) scores during surgery, activity at rest, postoperative blood pressure, and heart rate, also the sedation for femoral, lateral cutaneous femoral nerve obturator and sciatic nerve (FLOS) blocks. Compared with neuraxial (spinal/epidural) anesthesia, PNB (FLOS Block) minimizes hypotension, minimizes urinary retention, improves patient satisfaction, ambulation restrictions, and eliminates the risk of spinal hematoma and infection. Results: The finding suggests a decreased requirement of opioids in the PNB technique (FLOS Block). Pain scores, assessed by subjective VAS scale, were accurately handled in all the patients reviewed, with good pain control with PNB (FLOS Block). PNB (FLOS Block) provided stable hemodynamic, prolonged, and better postoperative analgesia. Intraoperative anesthesia was very satisfactory for surgery. The requirement of total doses of rescue analgesics, VAS score peroperatively for 48 h, the incidence of side effects, and complications were very few and acceptable. Conclusion: A femoral, sciatic nerve block with obturator and lateral femoral cutaneous nerve block may be an option to the spinal epidural anesthesia in the patients undergoing TKA. PNB (FLOS Block) showed similar patient satisfaction and postoperative analgesia to spinal-epidural anesthesia.

A new classification for spinal epidural hematoma following microendoscopic decompressive laminotomy: A prospective clinical and magnetic resonance imaging study of 245 patients.

The aim of this study was to develop a new radiological classification system for postoperative spinal epidural hematoma (SEH) using magnetic resonance imaging (MRI) and to determine the correlation of this classification system with clinical and radiological outcomes. This prospective study included a total of 245 consecutive patients (126 females, 119 males; mean age=72 years; age range=39-91 years) with single level spinal stenosis who were treated by microendoscopic decompressive laminotomy (MEDL). MRI was performed for all patients 24 hours postoperatively and at 12 months. SHEs were categorized into four grades using our new MRI-based classification system based on the measurement of dural sac area: Grade A, small hematoma with a round shape; grade B, small hematoma that show no round shape; grade C, moderate hematoma; grade D: severe hematoma. Patients were then divided into four groups according to their hematoma grades, Group A, 107 patients with grade A hematomas; group B, 47 with grade B; group C, 67 with grade C; group D, 24 with grade D. Also, patients who had neurological deterioration or who pain resistant to medical treatment were treated surgically, and those were assigned to group H+(14 patients). The study, therefore, contained five groups. Clinical evaluation was done using Japanese Orthopaedic Association (JOA) score preoperatively and at 12 months postoperatively. No significant difference existed among groups in the preoperative median measurement of the dural sac area, which were 0.90 cm2 in group A, 0.80 cm2 in group B, 0.70 cm2 in group C, 1.1 cm2 in group D, and 0.80 cm2 in group H+ (p=0.076). At the postoperative 12-month measurement, no significant difference was noted among groups A (2.05 cm2), B (1.80 cm2 ), and H+ (1.90cm2) (A vs B: p=0.891, A vs H+: p=0.089, B vs H +: p=0.933). The measurements were greater in groups A and B than in groups C and D (p<0.05). Also, larger dural sac areas were determined in group H+ (1.90cm2) compared to Groups C (1.80 cm2) and D (1.60 cm2) but the difference reached no statistical significance (p=0.078). In preoperative JOA scores, there were no significant differences among groups (p>0.05). At 12-month JOA scores, no significant difference was observed between groups A and B (p=0.061) and between groups C and D (p=0.511). The scores were higher in groups A and B than in groups C and D (p<0.05). It seems that the narrower the preoperative dural sac area, the better the clinical symptoms of the patients with SEHs based on our new MRI-based classification system. This classification may be useful to predict the clinical status of these patients at one-year follow-up. Level IV, Diagnostic study.

Delayed Onset Postoperative Spinal Epidural Hematoma after Lumbar Spinal Surgery: Incidence, Risk Factors, and Clinical Outcomes.

Background Posterior spinal epidural haematoma (PSEH) often develops within 24 hours after surgery. On rare occasions, PSEH occurs after 3 days and up to two weeks and is classified as delayed-onset PSEH. Due to its rarity, previous studies have only described the clinical features, whereas risk factors have not been assessed. Methods Patients who developed PSEH requiring haematoma evacuation between December 2013 and January 2020 were included and divided into the early-onset (group A) and delayed-onset (group B) groups based on the time of symptom onset (>72 hours). For each PSEH patient, 3 controls (group C) who did not develop PSEH in the same period were randomly selected. Clinical features were compared among the three groups, and multiple logistic regression analysis was performed to identify the risk factors for groups A and B. Results Thirty-two patients (0.35%) were identified as having early-onset PSEH (occurring at 10.68 ± 11.5 h), and 15 (0.16%) patients had delayed-onset PSEH (occurring at 130.60 ± 61.78 h). When comparing groups A and B, group A showed a higher rate of multilevel procedures, lower drainage, lower APTT, and higher JOA score at discharge. Multiple logistic regression analysis identified multilevel procedures (OR: 5.62, 95% CI: 1.84-17.25), postoperative systolic blood pressure (SBP) (OR: 1.10, 95% CI: 1.06-1.15), and abnormal coagulation (OR: 5.68, 95% CI: 1.74-18.52) as independent risk factors for group A, whereas postoperative SBP (OR: 1.10, 95% CI: 1.04-1.16) and previous spinal surgery (OR: 4.74, 95% CI: 1.09-20.70) at the same level were risk factors for group B. Conclusions Our study revealed that the overall incidence of delayed-onset PSEH was 0.16% in posterior lumbar spinal surgery and that its risk was different from that of early-onset PSEH. If patients with such risk factors develop neurological deficits 3 days after initial surgery, surgeons should be aware of the possibility of delayed-onset PSEH.

Incidence and Risk Factors for Symptomatic Spinal Epidural Hematoma Following Posterior Thoracic Spinal Surgery in a Single Institute.

Study Design:Case-control study.Objectives:To investigate the incidence of symptomatic spinal epidural hematoma (SSEH) and recognize its risk factors in a cohort of patients undergoing posterior thoracic surgery in isolation.Methods:From January 2010 to December 2019, patients who developed SSEH after posterior thoracic surgery and underwent hematoma evacuation were enrolled. For each SSEH patient, 2 or 3 controls who did not develop SSEH and underwent the same procedures with similar complexity at the same section of the thoracic spine in the same period were collected. The preoperative and intraoperative factors, blood pressure-related factors and radiographic parameters were collected to identify possible risk factors by comparing between the 2 groups.Results:A total of 24 of 1612 patients (1.49%) were identified as having SSEH after thoracic spinal surgery. Compared to the control group (53 patients), SSEH patients had significant differences in the APTT (p = 0.028), INR (p = 0.009), ratio of previous spinal surgery (p = 0.012), ratio of cerebrospinal fluid leakage (p = 0.004), thoracic kyphosis (p<0.05), local kyphosis angle (p<0.05), epidural fat ratio at T7 (p = 0.003), occupying ratio of the cross-sectional area (p<0.05) and spinal epidural venous plexus grade (p<0.05). Multiple logistic regression analysis revealed 3 risk factors for SSEH: cerebrospinal fluid leakage, the local kyphosis angle (>8.77°) and the occupying ratio of the cross-sectional area (>49.58%).Conclusions:The incidence of SSEH was 1.49% in posterior thoracic spinal surgeries. Large local kyphosis angle (>8.77°), high occupying ratio of cross-sectional area (>49.58%) and cerebrospinal fluid leakage were identified as risk factors for SSEH.

Spontaneous spinal hematoma

Background. Spontaneous spinal hematoma (SSH) is a rare condition that can result in severe functional disability and even death. But early detection and prompt intervention can substantially reduce the morbidity. We present a series of seven operated cases of SSH. Methods. All operated cases of SSH between 2017 and 2019 were studied. The demographic and clinical features, risk factors and imaging features were analyzed. The functional outcome at discharge and 6 months were assessed. Results. Seven operated cases of SSH with mean age 35(SD-20.9) were studied. Six cases were spontaneous spinal extradural hematomas (SSEDH) and one case was spontaneous spinal subdural hematoma (SSSDH). The most common site was cervicothoracic. Risk factors associated with SSH were thrombocytopenia, pregnancy, and necrotising pancreatitis. Two patients had preoperative Frankel’s grade A-B, three had grade C and two had D. The mean interval between the onset of symptoms and surgery was 4.7days. The functional outcome was dependent on the pre-operative functional status of the patient. Patients with SSEDH and thrombocytopenia had a poor outcome. Conclusion. SSH even though spontaneous may be associated with risk factors. The presence of thrombocytopenia and preoperative functional status predicted outcome. This is the only single institution case series to report thrombocytopenia as a factor predicting poor outcome.

A case of spontaneous spinal epidural hematoma mimicking transient ischemic attack

Spontaneous spinal epidural hematoma (SSEH), a disease with exact etiology unknown, is characterized by acute onset of neck or back pain and rapidly progressive nerve root or spinal cord compression. It is rare in clinical practices, with a prevalence of approximately one in a million. Due to the lack of population-based epidemiological survey data for SSEH, clinicians have a serious lack of understanding of the disease and are prone to miss the best time for treatment, leaving patients with neurological dysfunction which is difficult to recover. In this paper, we report a case of SSEH with rare clinical manifestations, to improve clinicians' understanding of SSEH. The patient was mainly characterized by episodic left lower limb weakness and had been misdiagnosed as TIA.

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome

ObjectiveThe aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome. MethodsWe reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability. ResultsOf the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A11, two A10, one A9) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal–mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach. ConclusionsA staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.