Abstract
Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.
Similar content being viewed by others
References
Adamson DC, Bulsara K, Bronec PR (2004) Spontaneous cervical epidural hematoma: case report and literature review. Surg Neurol 62(2):156–159 (discussion 159–160)
Bamford CR (1978) Spinal epidural hematoma due to heparin. Arch Neurol 35(10):693–694
Boyd HR, Pear BL (1972) Chronic spontaneous spinal epidural hematoma: report of two cases. J Neurosurg 36(2):239–242
Belinchón JM, Campos J, Merino J, Gallego JM, Barcia YC (2005) Chronic spontaneous lumbar epidural hematoma [Article in Spanish. Neurocirugia (Astur) 16(6):533–536
D’Angelo V, Bizzozero L, Talamonti G, Ferrara M, Colombo N (1990) Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. Surg Neurol 34(5):343–344
De Almeida GM, Bianco E, Shibata MK (1989) Encapsulated spinal epidural hematoma in an octogenarian. Surg Neurol 32(5):394–395
Devadiga KV, Gass HH (1973) Chronic lumbar extradural haematoma simulating disc syndrome. J Neurol Neurosurg Psychiatry 36(2):255–259
Felber S, Langmaier J, Judmaier W, Dessl A, Ortler M, Birbamer G, Piepgras U (1994) Magnetic resonance tomography in epidural and subdural spinal hematoma. Radiologe 34(11):656–661
Graziani N, Buillot P, Figarella-Branger D, Dufour H, Peragut JC, Grisoli F (1994) Cavernous angiomas and arterio-venous malformations of the epidural space: report of 11 cases. Neurosurgery 35:858–864
Groen RJ, Van Alphen HA (1996) Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 39(3):494–508
Groen RJ, Groenewegen HJ, van Alphen HA, Hoogland PV (1997) Morphology of the human internal vertebral venous plexus: a cadaver study after intravenous Araldite CY 221 injection. Anat Rec 249(2):285–294
Gundry CR, Heithoff KB (1993) Epidural hematoma of the lumbar spine: 18 surgically confirmed cases. Radiology 187(2):427–431
Gustafsson H, Rutberg H, Bengtsson M (1988) Spinal haematoma following epidural analgesia. Report of a patient with ankylosing spondylitis and a bleeding diathesis. Anaesthesia 43(3):220–222
Hancock JB, Field EM, Gadam R (1997) Spinal epidural hematoma progressing to Brown-Sequard syndrome: report of a case. J Emerg Med 15(3):309–312
Harik SI, Raichle ME, Reis DJ (1971) Spontaneously remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med 284(24):1355–1357
Harris ME (1969) Spontaneous epidural spinal hemorrhage. Am J Roentgenol Radium Ther Nucl Med 105(2):383–385
Kotilainen EM, Pajulo O (1997) Spontaneous epidural hematoma as a cause of sciatic pain in a schoolboy. Pediatr Neurol 17(4):350–352
Lederle FA, Cundy KV, Farinha P, McCormick DP (1996) Spinal epidural hematoma associated with warfarin therapy. Am J Med 100(2):237–238
Lee KS, McWhorter JM, Angelo JN (1988) Spinal epidural hematoma associated with Paget’s disease. Surg Neurol 30(2):131–134
Levitan LH, Wiens CW (1983) Chronic lumbar extradural hematoma: CT findings. Radiology 148(3):707–708
Lunardi P, Mastronardi L, Lo Bianco F, Schettini G, Puzzilli F (1995) Chronic spontaneous spinal epidural hematoma simulating a lumbar stenosis. Eur Spine J 4(1):64–66
Matsumura A, Namikawa T, Hashimoto R, Okamoto T, Yanagida I, Hoshi M, Noguchi K, Takami M (2008) Clinical management for spontaneous spinal epidural hematoma: diagnosis and treatment. Spine J 8(3):534–537
Morio Y, Kuranobu K, Yamamoto K (1993) Chronic spontaneous cervical epidural hematoma: report of a case presenting with only radicular symptoms. Spine 18(3):405–407
Muhonen MG, Piper JG, Moore SA, Menezes AH (1995) Cervical epidural hematoma secondary to an extradural vascular malformation in an infant: case report. Neurosurgery 36(3):585–587
Muthukumar N (2003) Chronic spontaneous spinal epidural hematoma—a rare cause of cervical myelopathy. Eur Spine J 12(1):100–103
Nakagami W, Yokota S, Ohishi Y, Ueda H, Takahashi Y, Sakuma M, Ohshima T, Kurita K (1992) Chronic spontaneous lumbar spinal epidural hematoma. Spine 17(12):1509–1511
Nehls DG, Shetter AG, Hodak JA, Waggener JD (1984) Chronic spinal epidural hematoma presenting as lumbar stenosis: clinical, myelographic, and computed tomographic features. A case report. Neurosurgery 14(2):230–233
Nuti C, Fotso MJ, Duthel R, Hatem O, Dumas B, Brunon J (2003) Non traumatic spinal epidural hematomas: report of twenty cases. Review of the literature and outcome aspects [Article in French]. Neurochirurgie 49(6):563–570
Pan G, Kulkarni M, MacDougall DJ, Miner ME (1988) Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging case report. J Neurosurg 68(5):798–801
Riffaud L, Morandi X, Chabert E, Brassier G (1999) Spontaneous chronic spinal epidural hematoma of the lumbar spine. J Neuroradiol 26(1):64–67
Rothfus WE, Chedid MK, Deeb ZL, Abla AA, Maroon JC, Sherman RL (1987) MR imaging in the diagnosis of spontaneous spinal epidural hematomas. J Comput Assist Tomogr 11(5):851–854
Shen CC, Wang YC, Yang DY, Wang FH, Shen BB (1995) Brown-Séquard syndrome associated with Horner’s syndrome in cervical epidural hematoma. Spine 20(2):244–247
Solheim O, Jorgensen JV, Nygaard OP (2007) Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery 61(1):E170–E171
Spanier DE, Stambough JL (2000) Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery. J Spinal Disord 13(1):46–49
Stendel R, Danne M, Schulte T, Stoltenburg-Didinger G, Brock M (2003) Chronic lumbar epidural haematoma presenting with acute paraparesis. Acta Neurochir (Wien) 145(11):1015–1018
Sweasy TA, Coester HC, Rawal H, Blaivas M, Mc Gillicuddy JE (1992) Ligamentum flavum haematoma: report of two cases. J Neurosurg 20:1506–1509
Van Schaeybroeck P, Van Calenbergh F, Van De Werf F, Demaerel P, Goffin J, Plets C (1998) Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases. Clin Clin Neurol Neurosurg 100(4):283–287
Vázquez-Barquero A, Abascal F, García-Valtuille R, Pinto JI, Figols FJ, Cerezal L (2000) Chronic nontraumatic spinal epidural hematoma of the lumbar spine: MRI diagnosis. Eur Radiol 10(10):1602–1605
Wu CT, Lee ST (1998) Spinal epidural hematoma and ankylosing spondylitis: case report and review of the literature. J Trauma 44(3):558–561
Zizka J, Eliás P, Michl A, Harrer J, Cesák T, Herman A (2001) Extensive spinal epidural hematoma: a rare complication of aortic coarctation. Eur Radiol 11(7):1254–1258
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sarubbo, S., Garofano, F., Maida, G. et al. Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature. Eur Spine J 18, 1555–1561 (2009). https://doi.org/10.1007/s00586-009-1175-6
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-009-1175-6