Is spontaneous spinal epidural hematoma in elderly patients an emergency surgical case ?

Abstract

Spontaneous spinal epidural hematoma (SSEH) is a rare condition requiring urgent diagnosis and treatment. Patients with SSEH typically present with acute onset of severe back pain and rapidly develop signs of compression of the spinal cord. The authors present a case with spontaneous resolution of SSEH which is extremely rare. We discuss a man who presented to our clinic with mild paraparesis at the seventh day of his symptoms. He had a history of poorly controlled hypertension and hypercholestrolemia requiring an antihyperlipidemic agent and anticoagulation. His upper level of hypoesthesia was at the third thoracic segment. Cervicothoracic SSEH was diagnosed by magnetic resonance imaging. Since there was a gradual recovery of the neurological deficits beginning 12 hours after the onset of symptoms, surgery was obviated and strict bed rest, serial neurological examinations, and pain controls with opiates were instituted. The neurological deficits showed complete recovery on the 25th day of the clinical course. SSEH is rare and immediate surgical decompression is suggested. Rapid neurological deterioration followed by early and progressive neurological recovery, confirmed by radiological resolution of the lesion, may indicate nonoperative treatment.

Spontaneous spinal epidural haematoma: A retrospective study of a series of 13 cases

“…11 Some authors state that epidural haematomas are venous and postulate that haemorrhages are caused by an increase in intrathoracic or intraabdominal pressure that is transmitted directly to the veins in the epidural venous plexus, resulting in vessel rupture. 4 Some authors suggest that epidural haematomas are arterial in origin [3][4][5]8,9 and are caused Table 2 Main MRI findings in the study patients. The implication is that venous haemorrhage would not be able to progress and cause compression of the intradural content.…”

“…[2][3][4][5]7,9,11,14,15,17,29 This theory has been questioned since the epidural venous plexus lacks valves and has a low pressure. 3,5,9 In most published cases, however, no arterial ruptures can be observed at the time of surgery, whereas patients do show epidural venous bleeding. 4 Some authors suggest that epidural haematomas are arterial in origin [3][4][5]8,9 and are caused Table 2 Main MRI findings in the study patients.…”

“…[5][6][7] However, there are some well-known predisposing factors, including blood dyscrasia, use of anticoagulant or antiplatelet drugs, tumours (ependymomas, neurinomas, or spinal cord gliomas), pregnancy, etc. 7,9,10,19,25 SSEH is considered a surgical emergency since early haematoma evacuation is associated with better functional outcomes. 4,5,8,[11][12][13][14][15][16][19][20][21] The most common clinical presentation features pain in the spinal column with a radicular component; this may be accompanied or followed by clinical signs of acute myelopathy.…”

“…1-18 Its estimated incidence rate is 1 new case per million population per year, accounting for 0.3% to 0.9% of all space-occupying spinal cord lesions. 1,[4][5][6]9,11,21,23,26,27 Conservative treatment is a reasonable option when neurological impairment is minimal or when patients experience significant spontaneous improvement during the first hours after onset. 3,4,[6][7][8][11][12][13]15,17,19,20,[22][23][24] Early clinical diagnosis and confirmation with an imaging study (preferably an MRI scan) are of vital importance.…”

Imaging of Spinal Metastatic Disease

“…Epidural hematoma is generally contained in the “less common” spectrum of intraspinal, extradural lesions, particularly in the absence of sentinel events such as surgical manipulation or trauma. Spontaneous epidural hematomas are rare but have been reported in patients on anticoagulation [64], those with vascular malformations [65] and in pregnancy [66]. A rare case report of spinal epidural hematoma associated with unsuspected metastatic lung cancer has been described [61].…”