Prognostic Factors and Treatment Efficacy in Spontaneous Spinal Epidural Hematoma: A Single Center Experience and Literature Review

Abstract

Background/aim: Spontaneous spinal epidural hematoma (SSEH) is a rare but serious condition, accounting for less than 1% of spinal lesions, with an incidence of 0.1 per 100,000 annually. Discovered by Jackson in 1869, around 40-50% of SSEH cases often lack a definitive cause, though risk factors, such as anticoagulant usage, vascular malformations, and hypertension are recognized. Symptoms vary from mild pain to severe neurological impairments like paraparesis, depending on the spinal cord compression level. Prompt treatment, usually involving spinal decompression and hematoma removal, is crucial, especially in cases of neurological decline. The study aims to provide comprehensive analysis of SSEH through examination of by patient cases, critical prognostic factors, and therapeutic strategies, based on demographics, clinical data, and outcomes observed at the Tri-Service General Hospital.

Patients and methods: This retrospective study, spanning 2003-2023 at the Tri-Service General Hospital, analyzed 14 patients with SSEH. It examined demographics, risk factors, clinical and radiological profiles, treatments, outcomes, and prognoses, using SPSS software (version 22.0) and adhering to the Modified Rankin Scale (mRS) and the American Spinal Injury Association (ASIA) impairment scale guidelines for data analysis.

Results: In this study of 14 patients with SSEH, 93% underwent urgent surgery, including total laminectomy or open-door laminoplasty, while 7% received conservative treatment. Post-surgery, 69.2% showed favorable outcomes (mRS ≤2) in the one-year follow-up, while 30.8% had poorer results (mRS 3-4). A significant negative correlation was noted between initial ASIA scores and one-year mRS outcomes, suggesting less initial impairment predicts better recovery. These findings indicated that a moderate positive correlation between treatment delay and one-year mRS scores. Nevertheless, factors, such as age, antiplatelet use, spinal levels with hematoma localization, and myelopathy signs observed before treatment did not demonstrate any significant effects on neurological outcomes during the one-year follow-up.

Conclusion: Patients with minor initial deficits or those receiving early surgery, preferably within 12-36 h of symptom onset, exhibit better neurological recovery. Poor prognosis correlates with high International Normalized Ratio (INR) on anticoagulants, hematoma size, lumbar involvement, or severe motor issues. Rapid surgical hematoma evacuation is advised. Our study supports recovery of neurological function following surgical intervention in all cases, highlighting the potential efficacy of surgical decompression even in severe and prolonged instances of SSEH.

Keywords: Spontaneous spinal epidural hematoma; neurofunctional outcomes; surgical intervention.

Figure 1. Thoracic spine MRI of an 80-year-old female. (A) T1-weighted imaging, sagittal view, revealing an isointense to hyperintense lesion in the dorsal epidural space from T6-T10; (B) T2-weighted imaging, sagittal view, revealing the lesion to be hyperintense; (C) T2-weighted imaging, axial view, arrow: epidural hematoma occupies the spinal canal and compresses the spinal cord. MRI: Magnetic resonance imaging.

Figure 2. A 69-year-old male with hematoma from C4 to T1. (A) T1-weighted imaging, sagittal view, revealing an isointense to hyperintense lesion; (B) T2-weighted imaging, sagittal view, revealing the lesion to be hypointense; (C) T2-weighted imaging, axial view, revealing an isointense lesion occupies the dorsal spinal canal and compresses the spinal cord.

Figure 3. A 44-year-old male with SSEH. (A) T1-weighted imaging, sagittal view, revealing an isointense lesion in the ventral epidural space from T6-T2; (B) T2-weighted imaging, sagittal view, revealing the lesion to be hyperintense; (C) T2-weighted imaging, axial view, revealing spinal cord compression on the ventral side. SSEH: Spontaneous spinal epidural hematoma.