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Case Reports
. 2015 Aug 18;7(8):e307.
doi: 10.7759/cureus.307.

Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation

Meng Huang  1 , Sean M Barber  1 , Marc Moisi  2 , Suzanne Powell  3 , Andreana Rivera  3 , Michael Zwillman  4 , James Rose  5
Affiliations
Case Reports

Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation

Meng Huang et al. Cureus. .

Abstract

Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.

Keywords: chiropractic manipulation; spinal arteriovenous malformation; spinal epidural hematoma.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. A) Axial T2 GRE image, B) Sagittal T2 FSE image, C) Axial T1 SE without contrast.
The images show an extradural heterogenous collection (arrows) in the left posterior epidural space, which extends from C2 to C6, compressing the thecal sac and spinal cord. The mass demonstrates heterogenous T2 signal and isointense to slightly increased T1 signal centrally with rim of susceptibility representing blood products in an epidural hematoma most likely in the acute to early subacute stage.
Figure 2
Figure 2. A and B) Axial and sagittal T1 SE images without contrast, C and D) Axial and sagittal T1 SE images with contrast and fat saturation.
The images show the extradural heterogenous collection in the left posterior epidural space, which demonstrates isointense to slightly increased T1 signal with minimal peripheral enhancement (arrows), displacing the spinal cord laterally.
Figure 3
Figure 3. Pathologic specimens and staining pattern
A) Hematoxylin and eosin stains of AVF displays a collection of variable caliber blood vessels, some with identifiable internal elastic laminae. B) Verhoeff - van Gieson (VVG) of AVM highlights the internal elastic laminae
See this image and copyright information in PMC

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