Spontaneous Recovery of Spinal Epidural Hematoma

Abstract

Spinal epidural hematomas are rare clinical entities that present with severe and acute pain followed by progressive motor and sensory deficit, and which have been associated with trauma, coagulopathies, arteriovenous malformation and neoplasm. [1][2][3] In the absence of significant trauma or other discernible cause, they have been described as spontaneous. [3][4] We report a case of spontaneous spinal epidural hematoma (SSEH) in a 45-year-old patient with typical presentation, diagnosed by magnetic resonance imaging (MRI) scan, who was managed conservatively in view of his rapid neurological improvement. Case ReportA 45-year-old man admitted to our hospital had suddenly developed severe pain at the lower neck and upper thoracic spine, and became paraplegic a few days before admission. He had some pain relief and experienced improvement in the weakness in his legs. There was previous history of fecal and urinary dysfunction. Apart from that there was no past medical history of note, and he was on no medication. Examination revealed a fit normotensive man with no abnormalities in the chest or cardiovascular system. There was no sign of meningeal irritation. Examination of cranial nerves was unremarkable. Tone and muscle power were normal in the upper limbs, but decreased in the proximal and distal part of the lower limbs. The deep tendon reflexes were present with reinforcement in the upper limbs but were exaggerated in the lower limbs. There was sensory loss below the T2 bilaterally. Laboratory investigations including CBC, prothrombin time, partial thromboplastin time, and platelet count, were normal. Electrocardiogram was unremarkable and random blood glucose and electrolytes were normal, as well as chest and plain x-ray of the spine. MRI showed a space-occupying lesion in the posterior part of the spinal canal at the level of D1 and D2 vertebrae, which was hypointense in T1 and T2-weighted image (Figure 1). The sagittal MR view clearly demonstrated the epidural location of the lesion and the spinal cord compression toward the anterior aspect of the spinal canal.On admission, the patient was found to have improved symptomatically. This was confirmed by a physical examination that showed paraparesis, and not complete paralysis as before. The patient's neurological state after admission, both subjectively and objectively, continued to improve dramatically. An operative approach was initially postponed, and ultimately abandoned. At follow-up two weeks later, the patient had no complaints, and he could stand and walk normally. On examination, his motor function and reflexes were normal, and he had no sensory deficit. An MRI two weeks later showed that the lesion had disappeared completely (Figure 2). DiscussionMattel et al. found over 300 cases of spinal hematoma in the world literature up to 1987. 5 Bruyn and Bosmu found 174 cases in the literature up to 1974. More than half the cases are spontaneous. 3,4,6 The patients' age in the cases reported in the literature range from six months to 79 years, but SSEH is m...