Spinal Hematoma Research Articles

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.

Symptomatic Postoperative Spinal Epidural Hematoma after Spinal Decompression Surgery: Prevalence, Risk Factors, and Functional Outcome.

Postoperative spinal epidural hematoma (pSEH) with symptomatic compression of nervous structures after spinal decompression surgery is a rare complication. Delayed evacuation may result in severe neurologic impairment. We present a large single-center analysis of the prevalence, potential risk factors, and functional recovery after pSEH. A retrospective review of our institutional database of spinal decompression surgery over 15 years yielded 6,024 consecutive patients. A total of 42 patients who had undergone surgical revision due to postoperative neurologic deterioration or intractable radiating pain and radiographically confirmed pSEH were allocated to the pSEH group. A matched 3:1 control group was formed (126 patients with the same surgical procedure, same year, same sex, and similar age). Charts, surgical reports, and radiographic data were reviewed for demographics, duration of symptoms, history of medical treatment, medication, comorbidities, radiographic extension, surgical strategy, and pre- and postoperative neurologic performance. Median follow-up was 3 months. Risk factors for pSEH, complete recovery, and recovery of neurologic symptoms were analyzed with univariable and multivariable logistic regression models. The prevalence of pSEH in this population was 0.69% (n = 42) with these locations: 7 of 1,284 (0.54%) cervical, 1 of 774 (0.12%) thoracic, and 34 of 3,966 (0.85%) lumbar. Use of anticoagulants (p = 0.003), pathologic coagulation values in the preoperative blood test (p = 0.034), and cigarette smoking (p = 0.003) were identified as independent risk factors of pSEH. Surgery in more than one level showed a trend toward an increased risk of pSEH. Pain as the only symptom (p = 0.0001) was a significant predictor of complete recovery. Patients symptomatic with paraplegia (p = 0.026) had a significantly higher risk of a poor neurologic outcome without full recovery of neurologic symptoms. The prevalence of pSEH was lower than previously reported incidences. Use of anticoagulants, pathologic coagulation values, and cigarette smoking were identified as independent risk factors of pSEH. Functional outcome was related to the duration between hematoma evacuation and the clinical presentation of symptomatic pSEH.

Spontaneous spinal epidural hematoma presenting with paraparesis: A case report and review of literature

Spontaneous spinal epidural hematoma (SSEH) is a rare and devastating clinical entity. The incidence is considered to be 1 in million/year. SSEH manifests due to accumulation of blood in the epidural space causing compression of the spinal cord and leading to acute neurological deficit. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurological deficit. Magnetic resonance imaging (MRI) serves as the modality of choice in diagnosing spinal epidural hematoma. Decompressive laminectomy and hematoma evacuation is considered as the mainstay of treatment, although conservative treatment can be tried in limited cases. Here, we present the case of a 48-year-old male who presented with progressive neurologic deficit. MRI revealed spinal epidural hematoma at T10-L4 level with cord compression which was promptly evacuated. Functional recovery was achieved after the surgical intervention.

Spinal Subdural Hematoma in a Young Adult with Hemophilia A: A Case Report

Hemophilia is a set of hereditary hemorrhagic disorders of coagulation-dysfunction that can cause repeated bleeding in various tissues and organs. And the patient can be disabled due to bleeding from bones, joints, and soft tissue, or die due to splenic rupture or intracranial bleeding. So it is crucial to detect the site of bleeding in hemophilia patients quickly. Spontaneous spinal canal hematoma is a rare complication of hemophilia, with less than 50 cases reported to date. It can be easily missed and cause serious harm to patients. Hematoma, if untreated, causes irreversible nerve damage by compression of the spinal cord. Early recognition and treatment are most useful to prevent spontaneous spinal canal hematoma. We describe the case of a 21-year-old man with severe lumbago for two days, who had hemophilia A for a decade. The patient was diagnosed with spinal subdural hematoma by magnetic resonance imaging (MRI) after ruling out other causes of lumbago and treated with drugs by a neurologist. The hematoma showed absorption by MRI after six months. In conclusion, spontaneous spinal canal hematoma is a severe complication of hemophilia, which is often missed. This successful case confirms the importance of early diagnosis and treatment of spontaneous spinal canal hematoma. We hope to increase the clinicians’ vigilance of this disease.

Accidental dural puncture-perioperative management.

Accidental dural puncture-perioperative management.

Rare Presentations of Spontaneous Spinal Epidural Hematomas in Children.

ABSTRACTSpontaneous spinal epidural hematomas are a rare presentation in children with very few case reports of spontaneous spinal hemorrhage in the pediatric age-group. There has to be a high index of suspicion of spontaneous spinal bleed in patients with acute-onset quadriparesis with no prior history of bleeding or trauma, as early diagnosis and surgical decompression is associated with better neurological outcomes.

Evaluation of clinical outcomes of 271 patients undergoing lumbar microdiscectomy in the light of literature

Aim: Lumbar microdiscectomy (LMD) is considered as a gold standard surgical technique for the treatment of patients with lumbar disc hernia (LDH) although various types of treatment are being developed. This study aimed to investigate the safety and efficacy of LMD in our clinic.Material and Methods: The study exclusively included 271 patients undergoing LMD due to LDH. Preoperative and postoperative (10th day, 1st month, and long-term) Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared. Clinical outcomes were analyzed retrospectively based on modified Macnab criteria. Complications were noted. SPSS Statistics 22.0 software package was used to analyse the data for pre- and postoperative VAS and ODI scores. A p value of 0.05 was considered statistically significant.Results: The mean length of stay in the operating room and hospital was 165.04±36.99 min and 1642.02±574.90 min, respectively. There was a significant decrease in postoperative VAS and ODI (%) scores compared to preoperative scores. Preoperative VAS and postoperative long-term VAS scores were 8.99±0.62 and 1.38±0.95, respectively whereas preoperative ODI (%) and postoperative long-term ODI (%) scores were 85.33±6.74 and 12.96±9.58, respectively (p0.001). The success rate for excellent or good outcomes according to the modified Macnab criteria was 87.45%. During surgery, cerebrospinal fluid (CSF) leak and dura defect developed in four patients (1.48%) and there was only dura defect in two patients (0.73%). After the surgery, recurrent LDH, spinal infection, and spinal epidural hematoma developed in seven (2.58%), three (1.11%), and one patient (0.37%), respectively.Conclusion: LMD is an effective and safe method in the treatment of LDH as it has low complication rates and high success rates.

Clinical management of spinal epidural hematoma

Clinical management of spinal epidural hematoma

Cough-induced paraplegia secondary to spontaneous spinal epidural hematoma: A case report

A spontaneous spinal epidural hematoma (SSEH) is a rare but significant neurological condition with hemorrhage leading to spinal cord damage, causing irreversible deficits. Its etiology is related to coagulopathy, vascular malformation, neoplasms, infections, minor vertebral traumas, and idiopath

Risk factors of postoperative spinal epidural hematoma: A single center experience of 3 years

Risk factors of postoperative spinal epidural hematoma: A single center experience of 3 years

Treatment results in spontaneous spinal epidural hematoma

Treatment results in spontaneous spinal epidural hematoma

A case report of spinal epidural hematoma presented conus syundrome

A case report of spinal epidural hematoma presented conus syundrome

A man in his sixties with acute back pain and increasing weakness in his lower limbs.

European and Norwegian consensus-based guidelines for the management of acute low back pain endorse red flag screening. Red flag symptomatology may ignore important information in the case history and clinical findings. An active man in his sixties presented with acute low back pain with radiation to the left thigh. A paramedic visited the patient at home and found no serious disease. Over a period of 4 hours, progressive loss of sensation and weakness in both legs developed. He arrived at the Accident and Emergency Department with paralysis, reduced sensation distal to the hips, absent reflexes, urinary retention and reduced sphincter tone. INR was 2.6. MR scan showed an intradural haematoma compressing Th9-L1, and dislocation of medulla and conus. This was followed by urgent Th10-12laminectomy and evacuation of subdural haematoma, and thereafter rehabilitation. Three years later, he has sequelae for spinal cord injury at level Th12 with impaired mobility and function in the legs. This case highlights that patients with ongoing anticoagulation and acute back pain have increased risk of spinal haematoma requiring emergency treatment. Anticoagulation therapy should therefore be included in red flag screening of acute back pain.

The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario?

Cohort. To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. This institutional review board approved study included 1587 patients from 2011 to 2018. Perioperative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. The patients who continued taking APD in the perioperative period had a longer length of hospital stay on average (2.5 ± 0.67 vs. 1.59 ± 0.76 and 1.67 ± 0.83, P < 0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused, and overall intra and postoperative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. The current study has observed no appreciable increase in perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. 4.

Lumbar neuraxial procedures in thrombocytopenic patients across populations: A systematic review and meta-analysis.

There is currently no consensus regarding the minimum threshold platelet count to ensure safe neuraxial procedures. Numerous reports describe the safe performance of lumbar punctures in severely thrombocytopenic patients but reports of neuraxial anesthetic procedures in thrombocytopenic patients are limited. To date, the focus on specific populations in contemporary reviews has failed to include any actual hematoma cases. This systematic review aggregates reported lumbar neuraxial procedures from diverse thrombocytopenic populations to best elucidate the risk of spinal epidural hematoma. MEDLINE, Embase, Cochrane, CINAHL databases were searched for articles about thrombocytopenic patients (<100,000 × 106/L) who received a lumbar neuraxial procedure (lumbar puncture; spinal, epidural, or combined spinal-epidural analgesia/anesthesia; epidural catheter removal), whether spinal epidural hematoma occurred. Of 4167 articles reviewed, 131 met inclusion criteria. 7476 lumbar neuraxial procedures were performed without and 33 procedures with spinal epidural hematoma. Within the platelet count ranges of 1-25,000 × 106/L, 26-50,000 × 106/L, 51-75,000 × 106/L, and 76-99,000 × 106/L there were 14, 6, 9, and 4 spinal epidural hematomas, respectively. An infection point and narrow confidence intervals were observed near 75,000 × 106/L or above, reflecting a low probability of spinal epidural hematoma in this sample. Of the 19 spinal epidural hematoma cases for which the onset of symptoms was reported, 18 (95%) were symptomatic within 48 h of the procedure. Spinal epidural hematoma in thrombocytopenic patients is rare. In this sample of patients, an inflection point and narrow confidence intervals are observed near a platelet count of 75,000 × 106/L or above, reflecting an estimated low spinal epidural hematoma event rate with more certainty given a larger sample size and inclusion of spinal epidural hematoma cases. Thrombocytopenic patients should be monitored, particularly in the first 48 h, and educated about symptoms concerning for spinal epidural hematoma.

Neuraxial Block for Delivery Among Women With Low Platelet Counts: A Retrospective Analysis

(Int J Obstet Anesth. 2018;35:4–9) Pregnant women with low platelet counts may be denied neuraxial block due to concerns about causing a spinal-epidural hematoma (SEH). As a result of this denial, they may not receive adequate labor analgesia. In the event of a cesarean delivery, there will be a need for general anesthesia, which has increased risk in parturients. The lowest safe platelet count to perform neuraxial block is unknown.

A Simplified Method of Staging Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Introduction - Branched and fenestrated stentgrafts are time-consuming and carry the risk of spinal cord ischaemia (SCI). SCI may be reduced when dividing the treatment in two stages, allowing temporary aneurysm sac perfusion (TASP).1,2 In the Cleveland experience, the thoracic stentgraft was implanted first and the abdominal/iliac and the bridging stentgrafts were implanted in the second stage.1 Staging can also be done by complete stentgrafting of the TAAA including bridging stentgrafts but leaving one gate open in the first stage.2 Both of these approaches may involve redo surgery either to the femoral or the axillary arteries. We decided to stage in a different fashion to avoid redo procedures and to prevent SCI. The aim of this study was to evaluate the results of this modified approach to staging. Methods - Twenty-five TAAA patients were treated with either t-branch or custom-made device (CMD) from Cook Medical. All patients were prospectively, consecutively registered between June 2013 and April 2017. After treating the first five patients in a one stage procedure and experiencing paraplegia due to SCI, we decided to implement TASP. Stage one was done by complete stentgrafting of the TAAA via open access to the femoral arteries and leaving all branches on the t-branch/CMD without connecting the target arteries. The brachial or axillary artery was used for percutaneous procedures only. In stage two, the bridging stentgrafts were implanted via open access to the axillary artery whereas the femoral artery was used for percutaneous procedures only. Twelve patients were excluded: Patients treated in one procedure (n =5), CMD’s with fenestrations only (n = 5) and ruptured aneurysms (n = 2). CTA was performed at three and six months postoperatively and yearly thereafter. Outcome measures were technical success, access complications, SCI, target vessel patency and mortality. Results - Thirteen patients had elective branched endovascular repair of TAAA in a staged fashion. Median time between stages was 8 weeks. All stentgrafts were successfully implanted except for failure to connect one target vessel in two patients. There were no access complications. Two patients had reversible SCI requiring spinal drainage, of which none acquired permanent paraplegia. One renal artery occluded during follow-up. Spinal hematoma as a complication to spinal drainage led to permanent neurological dysfunction in one patient. 30-day mortality was 0. There was no aneurysm rupture between the stages. Conclusion - This simplified method of staging avoids redo procedures in the femoral and the axillary arteries. This may reduce procedure time and, access complications and risk of SCI. SCI is a feared complication which was present in two cases in this series, although reversible.

Ultrasound-Assisted Technology Versus the Conventional Landmark Location Method in Spinal Anesthesia for Cesarean Delivery in Obese Parturients: A Randomized Controlled Trial

(Anesth Analg. 2019;129(1):155–161) For cesarean deliveries, spinal anesthesia is typically performed with the use of manual palpation. However, some patients present challenges to this method, particularly patients with imperceptible surface landmarks or those who are obese. Because spinal anesthesia placement may be more difficult in these patients, there is an increased likelihood of postdural puncture headache, paresthesia, or spinal hematoma. It has been proposed that preprocedure ultrasound scanning can assist care providers with spinal anesthesia placement, but not much research has been done on this subject. These investigators conducted their study to determine whether lateral-positioned ultrasound scanning would result in more precise needle insertions than a blind manual palpation technique for obese patients.

Epidural Hematoma Following Low Molecular-weight Heparin Prophylaxis and Spinal Anesthesia for Cesarean Delivery

(Int J Obstet Anesth. 2019;37:118–121) Epidural hematoma is a rare complication of spinal anesthesia while cesarean delivery (CD) is a risk factor for maternal venous thromboembolism. The more frequent use of pharmacologic prophylaxis with unfractionated or low–molecular-weight heparin (LMWH) in higher risk women has been recommended as a strategy to decrease venous thromboembolism. This case report described the development of a spinal-epidural hematoma in a parturient who received spinal anesthesia for a planned, repeat CD after receiving LMWH thromboprophylaxis.

Isolated Retrodental Epidural Hematoma Without Dens Fracture.

Traumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being<1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma. A 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.