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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 142-145

Spontaneous spinal epidural hematoma: A rare cause of quadriparesis in a young person


Department of Radiodiagnosis, GSL Medical College & Hospital, Rajamahendravaram, Andhra Pradesh, India

Date of Submission09-Mar-2019
Date of Decision29-Apr-2019
Date of Acceptance11-Sep-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Pramod Philip Nittala
Department of Radiodiagnosis, GSL Medical College & Hospital, NH-16, Lakshmipuram, Rajamahendravaram 533 296, Andhra Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ISJ.ISJ_18_19

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  Abstract 

Spontaneous spinal epidural hematoma (SSEH) is a rare condition with an incidence of 0.1 in 100,000 population. These are usually seen in the lumbar region in patients above 40 years and in the cervical and dorsal spine in younger patients. Posterior or dorsal epidural hematomas are more common than ventral hematomas. Patients present with sharp pain in the neck or back with or without neurological deficit. We present a case of a 20-year-old male who presented with quadriparesis and bowel and bladder incontinence for 5 days. No history of trauma or other aggravating factors were present. Magnetic resonance imaging revealed a posterior epidural hematoma with cord compression and edema. Patient underwent surgery and hematoma was evacuated. Patient symptoms improved gradually. Because of the severe preoperative neurological deficit and delay in surgery, patient had mild residual neurological deficit in the early post op period, which resolved over a period of two months

Keywords: Cord compression, laminectomy, MRI, quadriparesis, spontaneous spinal epidural hematoma


How to cite this article:
Joga PP, Nittala PP, Mishra A, Nyapathy V. Spontaneous spinal epidural hematoma: A rare cause of quadriparesis in a young person. Indian Spine J 2021;4:142-5

How to cite this URL:
Joga PP, Nittala PP, Mishra A, Nyapathy V. Spontaneous spinal epidural hematoma: A rare cause of quadriparesis in a young person. Indian Spine J [serial online] 2021 [cited 2021 Feb 28];4:142-5. Available from: https://www.isjonline.com/text.asp?2021/4/1/142/308198




  Introduction Top


Spontaneous spinal epidural hematoma (SSEH) is a rare condition first described by Blauby in 1808,[1] with an incidence of 0.1 in 100,000 people per year.[2]

It is usually seen in the fourth and fifth decade of life, commonly affecting the lumbar region in patients aged >40 years and the cervical and thoracic region in patients aged <40 years. Males are slightly more affected than females (M:F = 1.4:1).[2]

Clinical presentation is usually due to sharp neck pain or back ache which may progress to paraparesis or quadriparesis depending on the location. Ventral SSEH are uncommon as the dural sac is firmly attached to the posterior longitudinal ligament. The dorsal aspect is composed of fatty tissue, hence posterior or dorsal SSEH are more common.[1]

The present case involves a young male who presented with quadriparesis with no history of preceding trauma. In such a scenario, SSEH has to kept in the list of differential diagnosis as this condition requires prompt surgical management.


  Case Report Top


A 20-year-old male had presented to the casualty with complaints of sudden onset of quadriparesis for 5 days. There was history of loss of sensation to touch and pain up to xiphisternum for 3 days and bowel and bladder incontinence for 2 days. There was no history of trauma or fall. No co-morbidities were present. There was no history of addictions.

Patient had similar complaints (paraparesis) five years ago which was treated conservatively. No imaging was done at that time.

The laboratory tests such as complete blood profile, liver function test, blood creatinine, electrolytes, activated partial thromboplastin time, and international normalised ratio were within normal limits. The patient was normotensive.

The neurological examination revealed loss of strength of the bilateral upper and lower extremities. Loss of skin sensation was noted below the T4 vertebral level. Babinski reflex was positive bilaterally.

On MR imaging, an elliptical collection was noted in the posterior epidural space from C4 to C7 level, showing mild high signal on T1-weighted images and heterogeneous high signal intensity on T2-weighted images. The collection was seen to compress and displace the cord anteriorly. Subtle altered signal intensity changes were noted in the cord at that level, suggestive of cord edema [Figure 1] and [Figure 2].
Figure 1: Sagittal T2-weighted (1A) and T1-weighted (1B) MR images show an elliptical collection in the posterior epidural space at the C4 to C7 level with cord displacement and compression. Subtle altered signal intensities are noted in the cervical cord, s/o edema

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Figure 2: Axial T2-weighted (2A) and T1-weighted (2B) MR images show the posterior epidural hematoma at the C5 level causing anterior cord displacement and compression

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C4-C5 and C5-C6 laminectomy was done with evacuation of hematoma.

Patient gradually gained sensation and pain stimulus on the third postoperative day and was able to move his toes and fingers on the seventh postoperative day. MRI done 2 weeks later showed no residual epidural collection with postlaminectomy changes. Abnormal cord signal intensity was noted to persist [Figure 3]. In follow-up done 2 months after surgery, patient had complete recovery with no neurological deficit.
Figure 3: Postoperative sagittal T2-weighted (3A) and T1-weighted (3B) MR images show complete evacuation of the posterior epidural hematoma with postlaminectomy changes at the C5 to C7 level. Cervical cord edema is seen to persist

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  Discussion Top


Spontaneous spinal epidural hematoma is an uncommon condition that presents with acute neck pain or backache with or without neurological deficit. They can be divided into traumatic and nontraumatic (spontaneous) causes.

Traumatic spinal epidural hematoma follows any spinal surgery, vertebral fracture, lumbar puncture, or epidural catheterisation.

In spontaneous spinal epidural hematoma, 17–30% of patients have history of use of anticoagulants.[2] Other causes include vascular malformations, neoplasms, infections, and idiopathic causes. However, in approximately 40–60% of the cases, the etiology is unknown[1],[2]

Two hypotheses have been postulated:

  • 1) venous origin: rupture of the venous plexus in the spinal epidural spaces as these are valveless, and any increase in intrathoracic and intraabdominal pressure is directly transmitted to the epidural veins[1],[2],[3]


  • 2) Arterial: minimal impairment or laceration in the epidural artery caused by low pressure within the venous plexus compared to the intrathecal pressure.[1] The rapid compression of the spinal cord by the epidural hematoma also points to an arterial bleed.[3],[4]


Diagnosis of SSEH is difficult to establish prior to the onset of neurological deficit. Therefore, the differential diagnosis of SSEH should include pulmonary emboli, spontaneous pneumothorax, and acute myocardial infarction in the absence of neurological deficit and should include transverse myelitis, Guillain Barre Syndrome, epidural subarachnoid bleeding, and acute spinal cord ischemia in the presence of neurological deficit.

Our patient had neurological deficit and the other differentials were excluded by MRI imaging. Contrast MRI was performed and revealed no abnormal enhancement. MR angiography was not performed. Spinal arteriovenous malformation appears as multiple tortuous flow signal voids on both T1 and T2 images and was ruled out on MRI.

In the review of recently published case reports,[1],[2],[3],[4],[5],[6],[7] we found eight patients with SSEH, age range between 19 years and 70 years (5M, 3F). Spinal epidural hematoma was located in the cervical spine in three patients who presented with neck pain and upper limb weakness. In the rest, hematoma was located in the dorsal spine and these presented with paraparesis with one patient also having bladder incontinence.

All patients underwent surgical treatment, four undergoing hemilaminectomy, and the rest total laminectomy. Six of these patients had complete recovery with no residual neurological deficit while two patients had mild residual symptoms. Also included in this review is a case of 60-year-old female with epidural hematoma in the dorsal spine which the authors conclude was due to intake of herbal medicine.[6]

Imaging of choice is MRI. MRI can depict the location and size of hematoma. It can also reveal extent of spinal cord compression and cord edema.

Epidural hematoma appears as lenticular shape in the epidural space with well-defined borders, and may appear hyperintense on T1 images in the acute phase. With contrast, the periphery of the hematoma and adjacent dura may enhance. Ongoing hemorrhage will show a central enhancing area on post contrast T1 images.[2]

MRI can differentiate SSEH from its mimics such as epidural tumor or abscess, acute herniated intervertebral disc, acute spinal cord ischemia, spondylitis and transverse myelitis.

Treatment of choice is evacuation of the hematoma. Conservative management is indicated in patients who present with radicular symptoms without neurological deficit, patients who show improvement of the neurological deficit in the early phase and in those with deranged coagulopathy..[3],[4],[5]

Surgery within 24h after the onset of symptoms shows faster and often complete recovery, while surgery done later shows slower resolution of symptoms and with persisting residual neurological deficit. Prognosis is also affected by the level and severity of the preoperative deficit.

In conclusion, a diagnosis of SSEH should be considered in all patients presenting with acute quadriparesis and must be ruled out with MR imaging as this condition requires prompt surgical treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aycan A, Ozdemir S, Arslan H, Gonullu E, Bozkına C Idiopathic thoracic spontaneous spinal epidural hematoma. Case Rep Surg 2016;2016:5430708.  Back to cited text no. 1
    
2.
Figueroa J, DeVine JG Spontaneous spinal epidural hematoma: Literature review. J Spine Surg 2017;3:58-63.  Back to cited text no. 2
    
3.
Unnithan AKA A brief review of literature of sponatenous spinal epidural hematoma in the context of an idiopathic spinal epidural hematoma. Egypt J Neurosurg 2019;34:21. doi:10.1186/s41984-019-0046-7  Back to cited text no. 3
    
4.
Gopalkrishna CV, Amit D, Suresh N Spontaneous cervical epidural hematoma of idiopathic etiology: Case report and review of literature. J Spinal Cord Med 2012;35:113-7.  Back to cited text no. 4
    
5.
Baek BS, Hur JW, Kwon KY, Lee HK Spontaneous spinal epidural hematoma. J Korean Neurosurg Soc 2008;44:40-2.  Back to cited text no. 5
    
6.
Kim EJ, Ahn J, Kim SJ Spontaneous spinal epidural hematoma of the thoracic spine after herbal medicine: A case report. BMC Complement Altern Med 2018;18:291.  Back to cited text no. 6
    
7.
Zuo B, Zhang Y, Zhang J, et al. Spontaneous spinal epidural hematoma: A case report. Case Rep Orthop Res2018;1:26-33.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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