Spontaneous spinal epidural hematomas-Time is running out!

Abstract

Introduction: Spontaneous spinal epidural hematoma (SSEH) is the rarest cause of spinal cord compression, causing paraparesis or quadriparesis. They account for less than 1% (0.1 patients per 100,000 patients per year) of all spinal canal space-occupying lesions, thus resulting in a paucity of literature. Here, we report three cases of SSEH; all had a neurological deficit on presentation and were surgically managed with decompressive laminectomy and evacuation of the hematoma.

Case presentation: Of the three patients, one had a history of coronary artery disease and was on anticoagulants. In the remaining two, no cause could be identified. The hematoma was located at the thoracic region in 2 patients and at the cervical in one. Hematoma were located dorsal to cord in 2 patients and ventral in one. Two cases presented within 30 h of the onset of symptoms with the ASIA (American Spinal Injury Association) impairment scale (AIS) A and B neurology. Both showed a complete recovery during their latest follow-up. However, one case presented after 2 days with AIS A neurology and improved to AIS B post-operatively at 30 months follow-up.

Discussion: The myriad of symptoms and the need for an MRI for diagnosis have made SSEH difficult to diagnose clinically. Unlike other spinal pathologies where the severity of the preoperative neurological deficit is the best predictor of prognosis, in SSEH, time is the best predictor of prognosis. Our series highlights the fact that irrespective of the severity of the preoperative neurological deficit, timely diagnosis and early, adequate decompression surgery are essential for complete neurological recovery.

Fig. 1. Case 1.

Pre-operative sagittal (A) and axial (B) T2W MRI image demonstrating epidural hematoma over the posterior aspect of the cord extending from D5-D9 (note the isointense lesion on T2). C Intraoperative image showing a layer of epidural hematoma lying over the cord. D Evacuated hematoma. E 2-year follow-up sagittal T2WI normal spinal canal.

Fig. 2. Case 2.

Pre-operative T2WI sagittal (A) and axial (B) MRI anterior and right lateral epidural hematoma extending from D2-D7 with significant compression at D4 and D5 level (note the hyperintense with a heterogenous appearance on T2WI). C Intraoperative image showing epidural hematoma anterior to the cord after gentle retraction of the cord. D After decompression laminectomy and evacuation of hematoma. E 18-month follow-up sagittal MRI showing normal spinal canal.

Fig. 3. Case 3.

Pre-operative AP (A), lateral (B) X-ray images. Sagittal T1WI (C) and T2WI axial (D) MRI demonstrating dorsal epidural hematoma extending from C3-D1. E Post-operative lateral X-ray demonstrating laminectomy from C3-C6.