Spontaneous spinal epidural hematoma: A case report

doi:10.1016/j.jemermed.2004.11.023

The Journal of Emergency Medicine

Volume 28, Issue 4, May 2005, Pages 423-426

https://doi.org/10.1016/j.jemermed.2004.11.023 Get rights and content

Abstract

A 59-year-old man presented to the emergency department (ED) the day after a minor motor vehicle crash for evaluation of bilateral shoulder pain. He underwent ED evaluation for his back pain two more times before it was found that he had a spontaneous spinal epidural hematoma (SSEH). On the third visit, the patient had waxing and waning neurologic symptoms including lower extremity weakness and urinary retention. The diagnosis was made by MRI, and the patient was successfully treated with cervical hemilaminectomy at the cervicothoracic junction for evacuation of the epidural hematoma 5 days after the onset of back pain.

Introduction

Spontaneous spinal epidural hematoma (SSEH) is a relatively rare cause of back pain among emergency department (ED) patients. Although risk factors such as anticoagulant therapy, blood dyscrasias and arteriovenous malformations are well known, recent case reports have included other rarer causes such as thrombolytic therapy, cocaine use, chiropractic spinal manipulation, and valsalva maneuver (1, 2, 3, 4, 5, 6). The initial presentation is usually vague and many times the hematoma is not identified until the patient develops symptoms of cord compression hours or even days after the onset of pain.

Section snippets

Case report

A 59-year-old man with a past medical history of asthma, atrial fibrillation, and hypertension presented to our ED 1 day after being involved in a low-speed motor vehicle crash (MVC). His medications were coumadin, prednisone, inhalers, and diltiazem. The patient had pulled into his icy driveway the night before and his truck had slid into a brick wall at less than 5 miles per hour. He was restrained, did not hit his head, had no loss of consciousness, and had no instantaneous neck or back pain.

Discussion

Over 300 cases of spontaneous spinal epidural hematoma have been described in the literature. Spinal epidural hematoma is spontaneous with no identifiable cause in 40–50% of reported cases; and 25–30% of cases are associated with the use of anticoagulants (7, 8). Traumatic spinal epidural hematoma, including vertebral fractures or obstetrical birth trauma, is relatively uncommon (9). Iatrogenic causes include lumbar puncture and epidural anesthesia. The male/female ratio is 1.4:1, and the

Conclusion

It is important to keep in mind the diagnosis of spontaneous spinal epidural hematoma in the evaluation of back pain in the emergency department. More individuals are being placed on anticoagulation therapy due to an increasing number of indications (21), so it is important to have a heightened awareness of this entity. In addition, spinal epidural hematoma is spontaneous in 40–50% of cases. Thus, physicians should not have a false sense of comfort in managing back pain in the absence of

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Cited by (31)

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Citation Excerpt :
A hemorrhage is thought to originate from spontaneous rupture of the posterior epidural venous plexus and leads to compression of the spinal cord and nerve roots. It may affect any level of the spinal canal, but it most frequently affects the cervicothoracic region (1,2). Antiplatelet and anticoagulation therapies are known predisposing factors for SSEH (3).
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Spontaneous spinal epidural hematoma (SSEH) is an unusual cause of spinal cord compression, requiring emergency diagnosis and treatment. We report a case of SSEH, and discuss its early diagnosis and rapid surgical intervention. A 46-year-old man was brought to our emergency department because of sudden-onset, rapidly-progressive paraplegia and acute urinary retention. Magnetic resonance imaging revealed an epidural mass lesion in the posterior epidural space from T9 to T11 in the spinal canal. The patient underwent emergency decompression laminectomy within 4 hours of symptom onset and recovered fully within 1 week. In patients with SSEH, early surgery is crucial to ensure a favorable outcome.
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Citation Excerpt :
The posterior epidural venous plexus is believed by some to be the most likely culprit, due to the predominance of posterolateral hematomas and the segmental distribution of SSEH (3,7). Others, however, assign an arterial rupture to be the origin of the hematoma as the intrathecal pressure is more than the venous epidural pressure (8). Although some authors have reported good outcomes with conservative management, evacuation of the hematoma by surgical decompression remains the treatment of choice (3,4,7,10,11).
Background: Spontaneous spinal epidural hematoma (SSEH) is a rare cause of spinal cord compression that requires emergency investigation and treatment. Prompt diagnosis is essential to prevent morbidity and mortality. Objectives: Our goal was to report a case of SSEH, and to review the literature on the topic, looking particularly at the factors influencing post-operative outcome, and the symptoms and signs that would lead one to consider this rare diagnosis. Case Report: A 36-year-old man presented to the Emergency Department with paraplegia and a sensory level at T4. There was no history of trauma and he was not taking any medications. Magnetic resonance imaging revealed a large non-enhancing posterior epidural mass lesion between C7 and upper T4, causing severe cord compression at T1–T3. Post contrast scans revealed no rim enhancement. Blood investigations were unremarkable, with an international normalized ratio of 1.1. He underwent urgent decompression laminectomy within 12 h of symptom onset. Intraoperatively, thick clotted blood and prominent epidural vessels were seen. Histology revealed engorged vessels with hemorrhage and clot in the extravascular tissues. Post-operatively, the impaired neurological status remained unchanged. Conclusion: SSEH is a rare cause of spinal cord compression that requires prompt diagnosis and surgical intervention to prevent morbidity. Neurological outcome after surgical decompression depends on the severity of preoperative neurological deficits as well as the time between symptom onset and surgery.
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: Clinical Communications (Adults) is coordinated by Ron Walls, md, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts

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Clinical communicationsSpontaneous spinal epidural hematoma: A case report

Abstract

Introduction

Section snippets

Case report

Discussion

Conclusion

Clin Neurol Neurosurg

Am J Emerg Med

Arch Phys Med Rehabil

J Neurol Sci

Pediatr Neurol

Am J Med

Spontaneous spinal epidural hematoma. Another neurologic complication of cocaine?

Arch Neurol

Cervical epidural hematoma after spinal manipulation therapycase report

J Trauma

Spontaneous cervical epidural hematoma. A consideration of etiology

J Neurosurg

Spontaneous spinal epidural hematoma

Int Surg

Clinical communications
Spontaneous spinal epidural hematoma: A case report