Spontaneous Epidural Hematoma Research Articles

Non-traumatic spontaneous acute epidural haematoma – report of two cases and review of the literature

Epidural haematomas are usually associated with preceding head trauma. The entity of non-traumatic spontaneous acute epidural haematoma is rare and most commonly occurs in the presence of infectious disease. It can also occur in the presence of coagulopathy, vascular malformations of the dura mater and haemorrhagic tumours. Sickle cell disease, systemic lupus erythematosus, open heart surgery and haemodialysis have also been implicated as causative factors. The authors report two cases of spontaneous epidural haematomas (one of unknown aetiology and one from a coagulation disorder) and discuss the aetiological agents involved in this rarely described condition.

Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy

Background context A spontaneous epidural hematoma of the spine occurring during pregnancy is extremely rare. The development of a significant neurologic deficit may be rapid. Therefore, the neurosurgeon should be aware of the presentation, diagnosis and treatment options available. Purpose The authors report a case of a spontaneous epidural hematoma of the spine during the third trimester of pregnancy, which was successfully managed with surgical evacuation. The case is unique in that the patient demonstrated a subacute presentation. Study design The authors report a case of a 27-year-old primagravada presented with the subacute onset of progressive paraparesis. She became nonambulatory before admission. A magnetic resonance imaging study (MRI) demonstrated ventral epidural compression in the upper thoracic region. Methods A retrospective review of a case of spontaneous epidural hematoma of the spine during pregnancy was performed. The inpatient and outpatient charts were used to gather clinical information of the case, and the pertinent radiographs and images were reviewed. Results An urgent cesarean section was performed followed by evacuation of the epidural hematoma. The decompression was performed by means of a thoracic laminectomy with partial facetectomy. The patient had a prompt return of neurologic function. Conclusion Spontaneous epidural hematoma of the spine should be suspected in the setting of acute back or neck pain with or without an associated progressive neurologic deficit. Spine surgeons and obstetricians should also recognize that a spinal epidural hematoma during pregnancy may also present subacutely, as illustrated in our case. Prompt diagnosis may be made with MRI, and evacuation of the hematoma should be performed, ideally before the onset of neurologic signs or symptoms. The prognosis for return of neurologic function is good after urgent evacuation.

Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy*1

<h2>Abstract</h2><h3>Background context</h3> A spontaneous epidural hematoma of the spine occurring during pregnancy is extremely rare. The development of a significant neurologic deficit may be rapid. Therefore, the neurosurgeon should be aware of the presentation, diagnosis and treatment options available. <h3>Purpose</h3> The authors report a case of a spontaneous epidural hematoma of the spine during the third trimester of pregnancy, which was successfully managed with surgical evacuation. The case is unique in that the patient demonstrated a subacute presentation. <h3>Study design</h3> The authors report a case of a 27-year-old primagravada presented with the subacute onset of progressive paraparesis. She became nonambulatory before admission. A magnetic resonance imaging study (MRI) demonstrated ventral epidural compression in the upper thoracic region. <h3>Methods</h3> A retrospective review of a case of spontaneous epidural hematoma of the spine during pregnancy was performed. The inpatient and outpatient charts were used to gather clinical information of the case, and the pertinent radiographs and images were reviewed. <h3>Results</h3> An urgent cesarean section was performed followed by evacuation of the epidural hematoma. The decompression was performed by means of a thoracic laminectomy with partial facetectomy. The patient had a prompt return of neurologic function. <h3>Conclusion</h3> Spontaneous epidural hematoma of the spine should be suspected in the setting of acute back or neck pain with or without an associated progressive neurologic deficit. Spine surgeons and obstetricians should also recognize that a spinal epidural hematoma during pregnancy may also present subacutely, as illustrated in our case. Prompt diagnosis may be made with MRI, and evacuation of the hematoma should be performed, ideally before the onset of neurologic signs or symptoms. The prognosis for return of neurologic function is good after urgent evacuation.

Principles of management of osteometabolic disorders affecting the aging spine.

Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12-24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.

MR imaging of epidural hematoma in the lumbar spine.

To bring attention to the MR imaging appearance of epidural hematoma (EDH) in the lumbar spine as a small mass often associated with disk herniation or an acute event. This paper will show our experience with this entity and describe criteria for its MR imaging appearance. Thirteen cases of prospectively diagnosed EDH of the lumbar spine were compared with 12 cases of prospectively diagnosed prominent epidural extrusion. Our criteria were retrospectively evaluated by the two authors for their presence or absence in each case. The chi-square test for nominal data was applied. MR imaging criteria utilized to distinguish EDH from disk herniation at our institution include: (1) signal different from disk, (2) high signal on T1-weighted images, either centrally or peripherally, (3) teardrop- or egg-shaped mass, in the sagittal plane, (4) size greater than half the vertebral body height in a craniocaudal dimension, (5) primarily retrosomatic epidural location, (6) plasticity - the mass is seen to conform closely to the contours of bone (e.g., in the lateral recess), (7) little or no disk space narrowing unless associated with disc herniation. Chi-square analysis demonstrated each criterion to significantly differentiate between EDH and extrusion. Only six of 13 EDH cases went to surgery in spite of their relatively large size. Two of six patients were diagnosed as having epidural clot consistent with hematoma at the time of surgery. The four patients who were not diagnosed at surgery revealed only small disk herniations or fragments of disk. The occurrence of EDH is more frequent than previously suspected. Spontaneous EDH is frequently associated with disk herniation and acute events such as sneezing or coughing. Most cases of spontaneous EDH will resolve prior to surgery with only the minority becoming chronic in order to be seen at surgery as an encapsulated mass. MR imaging can reliably identify EDH and distinguish between EDH and large disk extrusions.

Paget's disease of the spine and its management.

A review of the literature was conducted to study the pathomechanics by which Paget's Disease of bone (PD) alters the spinal structures that result in distinct spinal pathologic entities such as pagetic spinal arthritis, spinal stenosis, and other pathologies, and to assess the best treatment options and available drugs. The spine is the second most commonly affected site with PD. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12-24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia, when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Since, in the majority of cases with pagetic spinal involvement, there are also coexisting osteoarthritic changes, antipagetic medical treatment alone may be disappointing. Therefore, one must be careful before attributing low back pain to PD alone. Five classes of drugs are available for the treatment of PD: bisphosphonates, calcitonins, mithramycin (plicamycin), gallium nitrate, and ipriflavone. Bisphosphonates are the most popular, and several forms have been investigated, but only the following forms have been approved for clinical use: disodium etidronate, clodronate, aledronate, risedronate, neridronate, pamidronate, tiludronate, ibadronate, aminohydroxylbutylidene bisphosphonate, olpadronate, and zoledronate. Several of these forms are still under investigation.

Hematoma of the ligamentum flavum in the lumbar spine:: Case report

Herniated nucleus pulposis, spondylotic spinal canal stenosis, neoplasms, infection, and spontaneous epidural hematoma [3,7,9] are the most common causes of spinal root and canal compression in the fourth to sixth decades of life. Ligamentum flavum hematoma, which is actually a type of epidural hematoma, is an extremely rare cause of spinal root or canal compression. We report the case of a 67-year-old man with a ligamentum flavum hematoma compressing the spinal canal at the L2-L3 level.

Spontaneous epidural hematoma following a shunt in an infant with congenital factor X deficiency

The authors describe a case of an infant with congenital factor X deficiency. The patient presented with a central nervous system hemorrhage followed by hydrocephalus. He underwent a ventriculoperitoneal shunt and, during the postoperative period, developed a spontaneous epidural hematoma, which was evacuated. The clinical and pathophysiological aspects of this case are discussed based on a literature review.

ANTICOAGULATION AND NEURAXIAL ANESTHESIA

Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics. 39 Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. Although hemorrhagic complications can occur after virtually all regional anesthetic techniques, bleeding into the spinal canal is perhaps the most serious hemorrhagic complication associated with regional anesthesia because the spinal canal is a concealed and nonexpandable space. Spinal cord compression from spinal hematoma may result in neurologic ischemia and paraplegia. Spinal hematoma may occur from vascular trauma from needle or catheter placement into the subarachnoid or epidural space. However, it may also occur in association with neoplastic disease or preexisting vascular abnormalities. Of special interest to the anesthesiologist are those spinal hematomas that have occurred spontaneously with or without the presence of antiplatelet or anticoagulation therapy. Over 100 spontaneous epidural hematomas have been reported, 25% of which are associated with anticoagulation therapy. 38 In a review of the literature between 1906 and 1994, Vandermeulen et al 41 reported 61 cases of spinal hematoma associated with epidural or spinal anesthesia. In 42 of the 61 patients (69%), the spinal hematomas associated with central neural blockade occurred in patients with evidence of hemostatic abnormality. Twenty-five of the patients had received intravenous or subcutaneous heparin, while an additional five patients were presumably administered heparin as they were undergoing a vascular surgical procedure. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran. Seventy were treated immediately before or after the spinal or epidural anesthetic. Needle and catheter placement were reported to be difficult or bloody in 15 (25%) patients. Thus, in 53 of the 61 cases (87%), either a clotting abnormality or needle placement difficulty was present. Neurologic compromise presented as progression of sensory of motor block or bowel/bladder dysfunction, not severe radicular back pain. Importantly, although only 48% of patients had partial or good neurologic recovery, spinal cord ischemia tended to be reversible in patients who underwent laminectomy within 8 hours of onset of neurologic dysfunction (Table 1) . In order to reduce the risk of spinal hematoma associated with central neural blockade, it is necessary to understand the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and also the clinical studies involving patients undergoing central neural blockade while receiving these medications. Recommendations for regional anesthetic management follow the consensus statements on Neuraxial Anesthesia and Anticoagulation published by the American Society of Regional Anesthesia. 9 , 18 , 21 , 34 , 40 Although this article will deal mainly with continuous techniques of major conduction blocks and anticoagulants, the same principles apply to all regional anesthetic techniques.

高齢者特発性頚髄硬膜外血腫の１例

高齢者特発性頚髄硬膜外血腫の１例

非外傷性急性脊髄硬膜外血腫の一例

Spontaneous epidural spinal hematoma is a relative condition which suddenly develops symptoms of spinal cord compression and needs appropriate surgical treatment immediately. We report one case of acute spinal epidural hematoma with spontaneous resolution.A 58-year-old woman experienced suddan on backpain and gait disturbance from muscle weakness. She had history of hypertention therapy. On admission, neurological examination showed paraplegia below T5. MRI showed mass lesion from C2 to C3, and CT after myerography revealed hematoma compressing her spinal cord. She was treated non-operatively. Her paraplegia recovered after 21 hours and complete recovery was more or less achieved 7 days after the onset. There was no recurrence of paraplegia. But MRI shows hematoma which is low-intensity on T1-weighted image and high-intensity on T2-weighted image exists 4 months after onset.In the case of acute spontaneous spinal epidural hematoma in which neurological deterioration is followed by early and sustained recovery, non-operative therapy may be considers.

Regional anesthesia in the anticoagulated patient: Yes or no

PINAL HEMATOMA is a rare and potentially catastrophic complication of spinal or epidural anesthesia. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetic cases. 1 Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. Although hemorrhagic complications can occur after virtually all regional anesthetic techniques, bleeding into the 'spinal canal is perhaps the most serious hemorrhagic complication associated with regional anesthesia because the spinal canal is a concealed and-nonexpandable space. Spinal cord compression from spinal hematoma may result in nenrologic ischemia and paraplegia. Spinal hematoma may occur due to vascular trauma from needle or catheter placement into the subarachnoid or epidural space (Fig 1). However, it also may occur in association with neoplastic disease or pre-existing vascular abnormalities. Of special interest to the anesthesiologist are those spinal hematomas that have occurred spontaneously with or without the presence of antiplatelet or anticoagulation therapy. Over 100 spontaneous epidural hematomas have been reported, 25% of which are associated with anticoagulation therapy. 2 In a review of the reports appearing in the literature between 1906 and 1994, Vandermeulen et al 3 discussed 61 cases of spinal hematoma associated with epidural or spinal anesthesia. In 42 of the 61 (68%) patients, the spinal hematomas associated with central neural blockade occurred in patients with evidence of hemostatic abnormality. Twenty-five of the patients had received intravenous or subcutaneous heparin; as they were undergoing a vascular surgical procedure, an additional five patients were presumably administered heparin. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran 70 immediately before or after the spinal or epidural anesthetic. Needle and catheter placement was reported to be difficult in 15 (25%) or bloody in 15 (25%) patients. Thus, in 53 of the 61 (87%) cases, either a clotting abnormality or needle placement difficulty was present. To reduce the risk of spinal hematoma associated with central neural blockade, it is necessary to understand the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and the clinical studies involving patients undergoing central neural blockade while receiving these medications. While this discussion will deal mainly with continuous techniques of major conduction blocks and anticoagulants, the same principles apply to all regional anesthetic techniques.

Síndrome sensitivomotor derecho como presentación de un hematoma epidural cervicotorácico espontáneo

A spontaneous cervical epidural hematoma is an infrequent cause of cord compression. The commonest clinical presentations are with paraparesia and tetraparesia. Transient hemiparesia is very rare and a sensory-motor syndrome is exceptional. A 38 year old man had sudden onset of spontaneous interscapular vertebral pain with bilateral root radiation. A few minutes later he started to have weakness and sensory loss in his right limbs. On clinical examination there was pain on pressure over the spinal apophyses of the T4 and T5 vertebrae, hemiparesia and hemi-hypoalgesia of the right limbs. After ten hours this had all returned to normal. MRI of the cord showed an epidural hematoma extending from C6 to T2. Coagulation studies and spinal arteriography were normal. The sensory motor syndrome is an unusual form of presentation of a spontaneous cervico-thoracic epidural hematoma. Root pain is a symptom of great value for orientation of a syndrome which would otherwise seem to be of central origin. The explanation for this clinical findings may be compression of both lateral cord pathways due to their particular blood distribution. Regarding therapeutic approach, this should be conservative, with close observation to see whether it will resolve spontaneously in a short period of time.

Spontaneous epidural hematoma as a cause of sciatic pain in a schoolboy

A previously healthy 13-year-old boy began to manifest radiating pain in his left leg after heavy physical exertion during judo training. He also had a sensation of numbness in his left buttock and leg. Initially, the patient was treated conservatively with a clinical diagnosis of disc herniation. However, following 3 months of conservative treatment, there was no relief of pain. Magnetic resonance imaging of the lumbar spine demonstrated an epidural mass causing compression of the dural sac at the L4-L5 disc level. During surgery, the L5 nerve root was found to be severely compressed in the spinal canal because of a chronic epidural hematoma. Following microsurgical removal of this hematoid mass, the patient had a good recovery. Spontaneous epidural hematomas in the lumbar region are rare, and only a few cases presenting with features simulating those caused by a disc herniation have been reported. Our patient represents the first such case described in a child.

P-4-501 - Spontaneous spinal epidural hematoma

A previously healthy 13-year-old boy began to manifest radiating pain in his left leg after heavy physical exertion during judo training. He also had a sensation of numbness in his left buttock and leg. Initially, the patient was treated conservatively with a clinical diagnosis of disc herniation. However, following 3 months of conservative treatment, there was no relief of pain. Magnetic resonance imaging of the lumbar spine demonstrated an epidural mass causing compression of the dural sac at the L4-L5 disc level. During surgery, the L5 nerve root was found to be severely compressed in the spinal canal because of a chronic epidural hematoma. Following microsurgical removal of this hematoid mass, the patient had a good recovery. Spontaneous epidural hematomas in the lumbar region are rare, and only a few cases presenting with features simulating those caused by a disc herniation have been reported. Our patient represents the first such case described in a child.

The Natural Resolution of a Lumbar Spontaneous Epidural Hematoma and Associated Radiculopathy

This is a report of a 37-year-old man who, while lifting a heavy box, developed severe low-back pain radiating into the right anterior thigh. The only clinical signs were paraspinal muscle spasm and a positive femoral nerve stretch test on the right. An electromyographic study demonstrated denervation in the right L2, L3, and L4 myotomes and paraspinal muscles. Magnetic resonance imaging (MRI) showed a large L1-2 anterior epidural hematoma compressing the spinal cord. The patient's pain gradually improved with conservative management and he returned to light work after 4 weeks. Repeat electromyographic and MRI studies were normal, indicating a resolution of the radiculopathy and hematoma. The diagnosis and management of spontaneous epidural hematomas are discussed.

Epidural hematoma of the lumbar spine: 18 surgically confirmed cases.

The authors report 18 cases of surgically proved spontaneous epidural hematoma of the lumbar spine. The clinical findings in spontaneous epidural hematoma were identical to those in acute disk herniation. Underlying disk abnormalities were common; the majority of hematomas (14 of 18, 78%) were associated with small concomitant disk herniations or underlying annular tears. The magnetic resonance imaging and computed tomographic findings were similar to those in extruded/free-fragment disk herniation. The strong coincidence between epidural hematoma and underlying disk disruption (annular tear or herniation) leads the authors to postulate that spontaneous epidural hematoma results from tearing of fragile epidural veins lying adjacent to the displaced anulus or nucleus.

Ligamentum flavum hematoma

Two patients presenting with signs and symptoms suggestive of nerve root compression secondary to extradural masses were found to have ligamentum flavum hematomas. Both patients had neurological deficits preoperatively and regained normal function postoperatively. There was no significant antecedent injury in either case. The symptom course was longer than that for spontaneous epidural hematoma. In one case, there was remodeling of bone, initially suggesting either infection or tumor.

Epidural Abscess Associated With Intravenous Drug Abuse in a Pregnant Patient

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.

Das spontane spinale epidurale Hämatom

Spontaneous epidural hematoma is seldom the cause of spinal cord compression. It was described for the first time by Blauby in 1808. We observed 7 patients from the age 16 up to 75 in the last 18 years. In 3 cases bleeding was caused by anticoagulant agents. In another 3 cases the cause of hemorrhage could not be proved. One patient suffered from bleeding by rupture of a spinal extradural hemangioma. Localisation was thoracic vertebral column in 3 cases and the lumbar vertebral column in 2 cases. In another 2 cases the level of the lesion was the cervical and cervical-thoracic region. All patients were operated on. 5 patients had an almost complete regression of the symptoms and neurological signs, one patient still had severe neurological defects. Another patient who had undergone dialysis for years before bleeding improved as well, but died three months later of embolism. Case reports, and a review of the literature are presented.