Spontaneous spinal epidural hematoma management with minimally invasive surgery through tubular retractors: A case report and review of the literature

Abstract

To report a minimally invasive paraspinal approach in the treatment of a case of spontaneous spinal epidural hematoma (SSEH). We additionally aim to review the relevant literature to enhance our knowledge of this disease. SSEH is an uncommon but potentially catastrophic disease. Currently, most appropriate management is emergence decompression laminectomy and hematoma evacuation. An 81-year-old woman was admitted to the neurology department with a chief complaint of bilateral numbness and weakness of the lower limbs and difficulty walking for 4 days with progressive weakness developed over the following 3 days accompanied with pain in the lower limbs and lower back. No history of trauma was reported. Magnetic resonance imaging of the thoracolumbar spine demonstrated an epidural hematoma extending from T-12 to L-5 with thecal sac and cauda equina displacement anterior. The patient was treated in our department with a minimally invasive approach. This operation method had been approved by Chinese Independent Ethics Committee. Three months following the operation, the patient had regained the ability to walk with the aid of a cane and myodynamia tests revealed normal results for the left lower limb and a 4/5 grade for the right limb. Importantly, no complications were exhibited from the surgical operation. The minimally invasive paraspinal approach through tubular retractors is demonstrated here as an effective alternative method for the treatment of SSEH.

Figure 1

Schematic diagram of this approach.

Figure 2

A, Sagittal T1-weighted MRI revealed a hematoma (isointense and slight hyperintense) located posterior to the thecal sac and cauda equine, extending from T12 to L5 (white arrows at the extremities of the mass). B, Sagittal T2-weighted MRI revealed a hematoma (isointense and hypointense, white arrows at the extremities of the mass). C, Axial T2-weighted MRI showed the hematoma (hypointense, white arrow) compressed the thecal sac and cauda equina (black arrow).

Figure 3

A, Dark red hematoma (white arrow) compressed the thecal sac. B, Thecal sac expanded and recovered (white arrow). C, The upper and lower edges of L2 vertebral plate were ground off (white arrows); zygapophysial joints were integrated. D, After surgery, drainage catheters (white arrows) were positioned in the intraspinal extradural. E, Each surgical incision was about 2 cm length (1 month postoperative).

Figure 4

MRI of the patient 9 days postoperative [(A) sagittal T1-weighted, (B) sagittal T2-weighted, and (C) axial T2-weighted) complete removal of the epidural hematoma, the thecal sac (white arrows) and spinal cord (black arrows) expansion and recovery.

Figure 5

CT scan (A) and reconstructed 3-dimensional CT scan (B and C) of this patient 9 days postoperative. The surgical channel of operation (white arrow and circle) and the zygapophysis joint integrity (black circle).