Symptomatic Spinal Epidural Hematoma Research Articles

A pig model of symptomatic spinal epidural hematoma.

The purpose of this study was to establish an animal model capable of simulating the development and decompression process of symptomatic spinal epidural hematoma (SSEH). A total of 16 male Bama miniature pigs were included in this study and randomly allocated into four groups: Group A (4h 20mmHg hematoma compression), Group B (4h 24mmHg hematoma compression), Group C (4h 28mmHg hematoma compression), and Group Sham (control). Real-time intra-wound hematoma compression values were obtained using the principle of connectors. Electrophysiological analyses, including the latency and amplitude of somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP), along with behavioral observations (Tarlov score), were performed to assess this model. ANOVA tests demonstrated significant differences in the latency and relative amplitude of SSEP and MEP between Groups C and Sham after 4h of hematoma compression and one month after surgery (P < 0.01). Behavioral assessments 8h after surgery indicated that animals subjected to 28mmHg hematoma compression suffered the most severe spinal cord injury. Pearson correlation coefficient test suggested a negative correlation between the epidural pressure and Tarlov score (r = -0.700, p < 0.001). With the progression of compression and the escalation of epidural pressure, the latency of SSEP and MEP gradually increased, while the relative amplitude gradually decreased. When the epidural pressure reaches approximately 24mmHg, the spinal cord function occurs progressive dysfunction. Monitoring epidural pressure would be an effective approach to assist to identify the occurrence of postoperative SSEH.

Systemic Hypertension and Postoperative Symptomatic Spinal Epidural Hematoma: A Scoping Review.

Postoperative symptomatic spinal epidural hematoma (PSSEH) is a serious complication of spinal surgery that is associated with significant morbidity. Studies suggest that hypertension is a risk factor for the development of PSSEH. The aim of this review was to evaluate the literature reporting associations between hypertension and PSSEH. A comprehensive literature search was conducted using the MEDLINE/PubMed, Embase, and Cochrane Library databases to identify studies that investigated PSSEH and reported data on preoperative hypertension status and/or perioperative blood pressure (BP). Eighteen studies were identified for inclusion in the review. Observational data suggested that uncontrolled/untreated preoperative hypertension, extubation-related increases in systolic BP, and elevated postoperative systolic BP were associated with an increased risk of PSSEH. The overall quality of evidence was low because of the retrospective nature of the studies, heterogeneity, and lack of precision in reporting. Despite the limitations of the current evidence, our findings could be important in establishing preoperative BP targets for elective spine surgery and inform perioperative clinical decision-making, while allowing consideration of risk factors for PSSEH. Well-controlled studies are required to investigate further the relationship between BP and PSSEH.

Widespread spontaneous spinal epidural hematoma treated with a combined technique using a flexible neuroendoscope after hemilaminectomy: A case report

Background: One-third of spinal epidural hematomas occur spontaneously, and these may be associated with the acute onset of severe paralysis. Here, we present a case of T4-L4 symptomatic spontaneous spinal epidural hematoma which was successfully removed using a flexible neuroendoscope after hemilaminectomy. Case Description: Using flexible neuroendoscopy, we successfully treated a T4-L4 spinal epidural hematoma in an 89-year-old Japanese female who spontaneously developed back pain and paraparesis. The hematoma was removed utilizing a hemilaminectomy at three vertebral levels (T11, T12, and L1), while the remaining hematoma debris was completely evacuated with flexible neuroendoscopy. Neurological improvement was observed immediately postsurgery. Conclusion: Flexible neuroendoscopy provided a less extensive surgical method for removing a T4-L4 spontaneous epidural hematoma.

Patient-reported Outcome After Surgical Evacuation of Postoperative Spinal Epidural Hematomas at One-year Follow-up.

Retrospective analysis of prospectively collected data from the National Swedish Spine Register (Swespine). The objective of this study was to evaluate the effects of symptomatic spinal epidural hematoma (SSEH) requiring reoperation on one-year patient-reported outcome measures (PROMs) in a large cohort of patients treated surgically for lumbar spinal stenosis. Studies exploring the outcomes of reoperations after SSEH are scarce and often lack validated outcome measures. As SSEH is considered a serious complication, understanding of the outcome after hematoma evacuation is important. After retrieving data from 2007 to 2017 from Swespine, we included all patients with lumbar spinal stenosis without concomitant spondylolisthesis who were treated surgically with decompression without fusion. Patients with evacuated SSEH were identified in the registry. Back/leg pain numerical rating scales (NRSs), the Oswestry Disability Index (ODI), and EuroQol Visual Analogue Scale were used for the outcome assessment. PROMs before and one year after decompression surgery were compared between evacuated patients and all other patients. Multivariate linear regression was performed to determine whether hematoma evacuation predicted inferior one-year PROM scores. A total of 113 patients with an evacuated SSEH were compared with 19527 patients with no evacuation. One-year after decompression surgery, both groups showed significant improvement in all PROMs. When comparing the two groups' one-year improvement, there were no significant differences in any PROM. The proportion of patients achieving the minimum important change was not significantly different for any PROM. Multivariate linear regression found that hematoma evacuation significantly predicted inferior one-year ODI (β=4.35, P =0.043), but it was not a significant predictor of inferior NRS Back (β=0.50, P =0.105), NRS Leg (β=0.41, P =0.221), or EuroQol Visual Analogue Scale (β=-1.97, P =0.470). A surgically evacuated SSEH does not affect the outcome in terms of back/leg pain or health-related quality of life. Commonly used PROM surveys may not capture neurological deficits associated with SSEH.

Ultraearly Hematoma Evacuation (

Early decompressive surgery within 24 hours improves the functional outcome of patients with traumatic spinal cord injury; however, little is known about the effect of early surgery for spontaneous spinal epidural hematoma (SSEH). In this study, we aimed to investigate the effectiveness of ultraearly hematoma evacuation (<12 hours) for SSEH. Patients with SSEH treated with surgical hematoma evacuation at our institution between January 2000 and July 2021 were retrospectively analyzed. Neurologic function was evaluated using the American Spinal Injury Association Impairment Scale (AIS). AIS grades A-C were defined as severe, and grades D and E as mild. AIS grades D and E at the final follow-up were considered favorable outcomes. Preoperative status and postoperative treatment results were compared between patients who had hematoma evacuation within 12 hours of onset and those who underwent surgery after 12 hours. Twenty-five consecutive patients were included in the analysis. Preoperatively, 23 patients (92.0%) had severe AIS. Fourteen (56.0%) patients underwent early surgery. At the final follow-up, 21 patients (84.0%) achieved favorable outcomes. Patients treated with ultraearly surgery had significantly better outcomes (100% vs. 63.6%, P= 0.03). Additionally, the time from onset to surgery was significantly shorter in patients with AIS improvement by 2 or more grades than that in patients with AIS improvement of 1 or less (median 8 hours vs. 14 hours, P= 0.0001). Ultraearly surgery within 12 hours for SSEH was associated with better functional outcomes.

Incidence of postoperative symptomatic spinal epidural hematoma requiring surgical evacuation: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to determine the incidence of symptomatic spinal epidural hematoma (SSEH) following spine surgery. We systematically searched for all relevant articles that mentioned the incidence of SSEH following the spine surgery published in the PubMed, Embase, and Cochrane Library databases through March 2022 and manually searched the reference lists of included studies. The Newcastle-Ottawa quality assessment scale (NOS) was used to assess the quality of the included studies. A fixed-effects or random-effects model was performed to calculate the pooled incidence of the totality and subgroups based on the heterogeneity. The potential publication bias was assessed by Egger's linear regression and a funnel plot. Sensitivity analysis was also conducted. A total of 40 studies were included in our meta-analysis based on our inclusion and exclusion criteria. The overall pooled incidence of SSEH was 0.52% (95% CI 0.004-0.007). In the subgroup analysis, the pooled incidence of SSEH in males and females was 0.86% (95% CI 0.004-0.023) and 0.68% (95% CI 0.003-0.017). Among the different indications, a higher incidence (2.9%, 95% CI 0.006-0.084) was found in patients with deformity than degeneration (1.12%, 95% CI 0.006-0.020) and tumor (0.30%, 95% CI 0.006-0.084). For different surgical sites, the incidences of SSEH in cervical, thoracic and lumbar spine were 0.32% (95% CI 0.002-0.005), 0.84% (95% CI 0.004-0.017) and 0.63% (95% CI 0.004-0.010), respectively. The incidences of SSEH in anterior and posterior approach were 0.24% (95% CI 0.001-0.006) and 0.70% (95% CI 0.004-0.011), respectively. The pooled incidence of SSEH was five times higher with minimally invasive surgery (1.94%, 95% CI 0.009-0.043) than with open surgery (0.42%, 95% CI 0.003-0.006). Delayed onset of SSEH had a lower incidence of 0.16% (95% CI 0.001-0.002) than early onset. There were no significant variations in the incidence of SSEH between patients who received perioperative anticoagulation therapy and those who did not or did not report getting chemopreventive therapy (0.44%, 95% CI 0.006-0.084 versus 0.42%, 95% CI 0.003-0.006). We evaluated the overall incidence proportion of SSEH after spine surgery and performed stratified analysis, including sex, surgical indication, site, approach, minimally invasive surgery, and delayed onset of SSEH. Our research would be helpful for patients to be accurately informed of their risk and for spinal surgeons to estimate the probability of SSEH after spine surgery.

Incidence and risk factors of postoperative symptomatic spinal epidural hematoma in cervical spine surgery: a single center, retrospective study of 18,220 patients.

The goal of this research is to explore the incidence and risk factors of symptomatic spinal epidural hematoma (SSEH) following cervical spine surgery. Patients with SSEH from January 2009 to February 2019 were identified as hematoma group. Two control subjects without SSEH were randomly selected for each patient in SSEH group as control group. We collected gender, age, body mass index (BMI), ossification of the posterior ligament (OPLL), comorbidities, anti-platelet or anti-coagulate treatment, coagulation function, segments, instrumental fixation, surgical approach, surgical procedure, duration of surgery and estimated blood loss, which might affect the occurrence of symptomatic epidural hematoma. T-test and Chi-square test were used to univariable test. Multifactor logistic regression analysis was used to investigate the correlation with symptomatic epidural hematoma, furthermore its causes were explored. Among 18,220 patients, 43 subjects developed SSEH, the incidence was 0.24%. The median time from the end of index surgery to SSEH was 150 min (25 and 75 percentile: 85 min to 290 min). The neurologic function before evacuation by modified Frankel scale is grade B in 5 patients, C in 32 patients, grade D in 6 patients. All patients' symptoms relieved partially or completely after evacuation. All patients with neurologic deficit worse than grade C pre-evacuation had at least one-grade improvement except for one patient. Multifactor logistic regression revealed OPLL involved segments are significantly correlated to the incidence of postoperative symptomatic epidural hematoma (P < 0.05), with a cut-off value of 1.5 levels. OPLL involved segments are significantly correlated to the incidence of postoperative symptomatic epidural hematoma.

Post-Operative Spinal Epidural Hematoma: Are We Discontinuing Aspirin Early Enough?

Retrospective cohort study. (1) To compare the risk of Spinal Epidural Hematoma (SEH) associated with specific pre-operative and post-operative anticoagulation (AC) and antiplatelet medications (APM). (2) To define the incidence of SEH and identify risk factors for SEH in our population. Thoracolumbar surgeries between October 2009 and March 2020 were collected. Patients who underwent incision and drainage of a symptomatic SEH were identified. AC and APM was recorded 14 days pre-operatively and post-operatively. Demographics and intra-operative factors were recorded. Relative risk with 95% confidence interval was used, with Bonferroni-corrected P-values <.05 used for significance. 9307 surgeries were identified. 177 (1.9%) patients returned to the OR within 30 days, 37 of whom (.39%) returned due to SEH. Seven patients were on either AC or APM pre-op, and sixteen post-op. Five were on aspirin pre-operatively (RR 3.2, 95% CI 1.25-8.22, P = .015). Risk was not increased in patients on multiple agents. No AC or APM demonstrated increased risk of hematoma post-operatively, despite trends toward significance with multiple agents. The use of a drain and complicated hypertension were associated with increased risk of SEH. Pre-operative aspirin is associated with increased risk of SEH, even when appropriately discontinued. Appropriately dosed post-operative anticoagulation does not increase the risk of SEH, though being on multiple agents trends toward statistical significance and should be better studied. Surgeons should be vigilant and carefully monitor patients on pre-operative antiplatelet medications for spinal epidural hematoma.

Which Criterion for Wound Drain Removal is Better Following Posterior 1-Level or 2-Level Lumbar Fusion With Instrumentation: Time Driven or Output Driven?

Case-control study. To compare the outcomes of 2 different criteria (time driven and output driven) for wound drain removal and identify which one is better. 743 patients who underwent posterior lumbar fusion with instrumentation involving 1 or 2 motion segments were enrolled in this study. Based on the different criteria for drain removal, the patients were divided into 2 groups. The drains were discontinued by time driven (postoperative day 2) in group I and output driven (<50 ml per day) in group II. Demographic characteristics, perioperative parameters and clinical outcomes were compared between the 2 groups. The demographic characteristics in both groups were comparable. The postoperative drain output, total blood loss, postoperative timing of ambulation, and postoperative duration of hospital stay in group I were lower than those in group II (P < 0.001). There was a higher proportion of patients requiring postoperative blood transfusion in group II, but not to a level of statistical significance (P = 0.054). There was no statistical significant difference in the incidence of surgical site infection (SSI) or symptomatic spinal epidural hematoma (SEH) between the 2 groups (P > 0.05). This study reveals that there are more benefits of wound drain removal by time driven than that by output driven for patients undergoing posterior 1-level or 2-level lumbar fusion with instrumentation, including less postoperative drain output, less total blood loss, earlier postoperative timing of ambulation and less postoperative duration of hospital stay without increasing the incidence of postoperative SSI or symptomatic SEH.

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).

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.

Research progress on early diagnosis, reasonable prevention and treatment of symptomatic spinal epidural hematoma following spinal surgery

Symptomatic spinal epidural hematoma (SSEH) following spinal surgery is rare but one of the serious complications. SSEH can leave devastating neurological consequences if missing the optimal timing for treatment. The early diagnosis of SSEH is critical to the neurologic recovery, and MRI examination can help to check the location and the scope of the hematoma and provide imaging information for surgical operation. The risk factors of SSEH can be divided into preoperative factors, intraoperative factors and postoperative factors. The occurrence of SSEH can be minimized by controlling the risk factors, exact hemostasis and reasonable perioperative management. Patients with mild paralysis can choose conservative treatment, while patients with severe or progressive nerve injury (manual muscle testing <3) and unendurable nerve root pain should choose to clean the hematoma and decompress the nerve as soon as possible.

Assessment of Postoperative Epidural Hematoma after Lumbar Microendoscopic Surgery

Introduction Symptomatic postoperative spinal epidural hematoma (SEH) is observed occasionally but rarely gets into serious complication after lumbar spinal surgery. It is also known that SEH occurs even in the endoscopic surgery. The purpose of this study is to assess characteristics and outcome of those cases which had SEH treated surgically after the initial microendoscopic surgery in the lumbar spine. Method From 2003 to 2015, total of 1249 patients with lumbar disc herniation or canal stenosis underwent microendoscopic discectomy or laminectomy in our institution. Traditional open spinal surgeries were compared with those microendoscopic surgeries. Six patients after microendoscopic surgery in the series required evacuation of SEH after the initial surgery were included in this study. Preoperative characteristics of the patients, clinical outcome and postoperative course were assessed. Result The incidence of SEH after microendoscopic surgeries required additional treatment was 0.48% (6 of 1249). The incidence of SHE after open spinal surgeries were 0.77% (11 of 1421). The initial procedure was microendscopic discectomy in three cases and microendoscopic laminotomy in three cases. One patient had hypertension, two patients had prediabetes and one patient had thrombocytopenia (12.110*3/μl) by hepatitis. Three cases were treated in the acute stage (within 24 hours after the surgery) and three cases were treated in the subacute stage (between 3 and 7 days after the surgery). In all cases, severe leg pain was appeared in short time. Two patients got muscle weakness. After the surgical evacuation of hematoma, all cases recovered from neurological symptoms and leg pain immediately. But one patient had repetitive leg pain after the evacuation with local anesthesia or general anesthesia. Finally Blood transfusion and factor VIII were required to stop SEH. Factor VIII activity of the patient was 58% at two days after the initial surgery. The patient fully recovered at six months after the initial surgery. Conclusion The incidence of SEH was not significant in comparison with a conventional method. It was considered that narrow epidural space by microendoscopic surgery affected dural compression by even a little bleeding. Basically, in preventing SEH, preoperative bleeding tendency, intraoperative bleeding, postoperative blood pressure and drainage should be confirmed. Even though, it was very difficult to detect the crucial factor of the symptomatic SHE, patient factor like bleeding and cerebrospinal pressure or iatrogenic factor like redundant invasion may lead to symptomatic SHE. Prompt treatment for symptomatic SEH was necessary.

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

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

Symptomatic Spinal Epidural Hematoma After Lumbar Spine Surgery: The Importance of Diagnostic Skills

Symptomatic spinal epidural hematoma (SEH) is a rare but serious complication that may occur after lumbar spine surgery. Prompt recognition of this complication depends on the diagnostic skills of perioperative nursing personnel, particularly postanesthesia care unit nurses. Analysis of a composite of patients undergoing spinal surgery suggests that neurological and functional outcomes of patients with symptomatic lumbar SEH often depend on the time interval between symptom onset and surgical evacuation of the hematoma. Clinicians should consider a diagnosis of symptomatic SEH if there is a change in the patient’s neurological status during the first several hours after lumbar spine surgery. Suspicion of postoperative symptomatic SEH should prompt clinicians to notify the responsible surgeon without delay.

Acute postoperative cervical spinal epidural hematoma.

The aim of this study was to assess the clinical presentation, causes or risk factors, treatment and outcomes of symptomatic acute postoperative cervical spinal epidural hematoma (APCSEH). The study retrospectively reviewed all patients who underwent open cervical spinal surgery between January 1, 2004 and October 31, 2008. Perioperative coagulation parameters, past medical history, age, gender, time to decompression, pre- and postoperative (decompression operation) neurological status, as well as the interval of hematoma formation and level of segments were reviewed. Potential risk factors for extradural hematomas were examined. Patients who were diagnosed with APCSEH underwent immediate surgical drainage of the hematoma. Over 2,338 cervical spinal surgeries were performed by the Orthopedic Spinal Disorder Group in our hospital between 2004 and 2008. Twelve (0.5%) cases of APCSEH were identified. Two-thirds of the patients had history of hypertensive disease or transitory hypertensive status after surgery. No patients had abnormal preoperative coagulation parameters, bleeding diathesis or developed intraoperative coagulopathy. All patients were treated with hematoma evacuation within 2 hours of the ultimately definitive diagnosis of hematoma. Acute postoperative cervical spinal epidural hematoma is a rare cause of postoperative neurological deterioration. Hypertensive disease and the method of multilevel cervical surgery appear to increase bleeding and predict formation of hematoma. Early diagnosis and evacuation of the hematoma can result in resolution of the neurological deficit.

Symptomatic spinal epidural hematoma after posterior cervical surgery: incidence and risk factors

Background contextThe true incidence of symptomatic spinal epidural hematoma (SEH) after surgery of the posterior cervical spine and risk factors for its development remain unclear. PurposeThe purpose of this study was to determine the 10-year incidence of symptomatic postoperative SEH and identify risk factors for its development. Study design/settingThis study is a retrospective observational study at a Canadian tertiary care spine center. Patient sampleThe study sample includes adult patients undergoing posterior surgery of the cervical spine. Outcome measuresThe outcome measures were the incidence of symptomatic postoperative SEH and risk factors for its development. MethodsSurgical procedure codes were used to identify study candidates. Using a standard data collection form, two independent reviewers manually searched paper and electronic medical records to extract patient-, treatment-, and complication-related data. Time to presentation, clinical findings, method of treatment, and intraoperative findings (when relevant) were recorded for patients with an SEH. The overall incidence of symptomatic SEH was calculated, and the categorical and continuous variables were summarized with percentages and means, respectively. Stepwise forward selection logistic regression analysis was performed to identify risk factors for the development of symptomatic SEH. ResultsFrom January 2002 to December 2011, 529 patients (356 men and 173 women; mean age, 56.7 years) were identified for study inclusion. The mean Charlson Comorbidity Index (CCI) was 0.65 (range, 0–8). Myelopathy was the most common surgical indication (n=293; 55.4%), with the largest subset of patients undergoing decompression with or without instrumented fusion (n=266; 50.3%). Symptomatic postoperative SEH was diagnosed in eight patients for an overall incidence of 1.5%. Postoperative nonsteroidal anti-inflammatory drug (NSAID) use and an increased CCI were identified as significant predictors of the development of a symptomatic SEH in our study cohort (p=.024 and .003, respectively). When all other variables remained constant, a 1-point increase in CCI was associated with 1.6 times higher odds of hematoma development, whereas postoperative NSAID use increased the odds 6.6 times. ConclusionsSymptomatic SEH may occur in up to 1.5% of patients undergoing posterior cervical spine surgery. Patients with a higher level of comorbid disease appear to be at increased risk of development of a symptomatic SEH, although avoidance of postoperative NSAIDs may decrease the risk of its development.

Postoperative spinal epidural hematoma (SEH): incidence, risk factors, onset, and management

Background contextSpinal epidural hematoma (SEH) is a rare, yet potentially devastating complication of spinal surgery. There is limited evidence available regarding the risk factors and timing for development of symptomatic SEH after spinal surgery. PurposeTo assess the incidence, risk factors, time of the onset, and effect of early evacuation of symptomatic SEH after spinal surgery. Study designMulticenter case control study. Patient sampleAll patients who underwent open spinal surgery between October 1, 1999, and September 30, 2006, at the National Hospital For Neurology and Neurosurgery (NHNN) and the Wellington Hospital (WH) were reviewed. Outcome measuresFrankel grade. MethodsPatients who developed SEH and underwent evacuation of the hematoma were identified. Two controls per case were selected. Each control had undergone a procedure with similar complexity, at the same section of the spine, at the same hospital, and under the same surgeon within 6 months of the initial operation. ResultsA total of 4,568 open spinal operations were performed at NHNN and WH. After spinal surgery, 0.22% of patients developed symptomatic SEH. Alcohol greater than 10 units a week (p=.031), previous spinal surgery (p=.007), and multilevel procedures (p=.002) were shown to be risk factors. Initial symptoms of SEH presented after a median time of 2.7 hours (interquartile range [IQR], 1.1–126.1). Patients who had evacuation surgery within 6 hours of the onset of initial symptoms improved a median of 2 (IQR, 1.0–3.0) Frankel grades, and those who had surgery more than 6 hours after the onset of symptoms improved 1.0 (IQR, 0.0–1.5) Frankel grade, p=.379. ConclusionsSymptomatic postoperative SEH is rare, occurring in 0.22% of cases. Alcohol consumption greater than 10 units a week, multilevel procedure, and previous spinal surgery were identified as risk factors for developing SEH. Spinal epidural hematoma often presents early in the postoperative period, highlighting the importance of close patient monitoring within the first 4 hours after surgery. This study suggests that earlier surgical intervention may result in greater neurological recovery.

Diagnosis and microsurgery of symptomatic spontaneous spinal epidural hematoma

Symptomatic spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of cord compression that needs emergent treatment. Without effective management of the symptomatic SSEH, irreversible severe spinal injury would be possible. We aimed to investigate the diagnosis and surgical management of symptomatic SSEH. Five cases of symptomatic SSEH with favorable neurological recovery after emergent microsurgery were prospectively analysed. The main clinical presentations were root pain and palsy. The main manifestations of MRI were long-segment epidural lesions of high intensity on T1- and T2-weighted images without enhancement. Laminectomy via posterior approach and hematoma removal were undergone for all patients. All patients achieved full neurological recovery without complications. MRI manifestation assisted with the main clinical symptoms may aid the preoperative diagnosis of SSEH, and the delay in obtaining preoperative Digital subtraction angiography is worthwhile, especially for those with progressive neurological deterioration.

Spinal Epidural Hematoma

Spinal epidural hematoma is a rare condition that usually presents with acute, severe pain at the location of the hemorrhage, with radiation to the extremities. It can rapidly develop to include progressive and severe neurologic deficit. The pathophysiology often remains unclear. However, epidural hematoma in the lumbar spine is best described as the result of internal rupture of the Batson vertebral venous plexus. Clinical evaluation of pain control and neurologic deficit is the most important tool in early diagnosis. Currently, MRI is the diagnostic method of choice. Regardless of the setting, symptomatic spinal epidural hematoma is typically managed with urgent surgical decompression of the spinal canal.