Spontaneous spinal epidural hematoma management: a case series and literature review

Abstract

Objective: Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH's 5.7% mortality-which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH's progression, outlining a best-practice therapeutic approach.

Materials and methods: Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines.

Results: Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare-only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts.

Discussion: The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

Keywords: Neurological disorders; Neurological manifestations; Neurosurgery; Outcomes research; Prognosis.

Figure 1

SSEH patient ASIA scores upon presentation (left column) and upon maximal resolution (right column). Out of 65 cases described (a, b), 15 were treated conservatively (c, d) and 50 were treated surgically (e, f). ASIA scores are indicated as colour.

Figure 2

92-year-old female with hematoma from C4 to T4 measuring 1.2 -cm thick and 12.3 cm in length. Improved from ASIA C to ASIA D with surgery.

Figure 3

76-year-old female with hematoma from T7 to L1 measuring 1.2-cm thick and 15 cm in length. Improved from ASIA D to E with surgery.

Figure 4

50-year-old female with hematoma from T1 to T5 measuring 0.65-cm thick and 8.9 cm in length. Improved from ASIA A to ASIA B with surgery.