Spontaneous spinal epidural hematoma management: a case series and literature review

Abstract

Objective:Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to acute neurological deficits. Standard therapy is decompressive laminectomy, although spontaneous recoveries have been reported. Sub-optimal therapeutic principles contribute to SSEH’s 5.7% mortality—which patient will benefit from surgery remains unclear. This study aims to investigate parameters that affect SSEH’s progression, outlining a best-practice therapeutic approach.Materials and methods:Literature review yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under American Spinal Injury Association (ASIA) score guidelines.Results:Fifty percent of SSEH patients do not fully recover. In all, 30% of patients who presented with an ASIA score of A did not improve with surgery, although every SSEH patient who presented at C or D improved. Spontaneous recovery is rare—only 23% of patients were treated conservatively. Seventy-three percent of those made a full recovery, as opposed to the 48% improvement in patients managed surgically. Thirty-three percent of patients managed conservatively had an initial score of A or B, all improving to a score of D or E without surgery. Regardless, conservative management tends toward low-risk presentations. Patients managed conservatively were three times as likely to have an initial score of D than their surgically managed counterparts.Discussion:The degree of pre-operative neural deficit is a major prognostic factor. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested. Decompressive laminectomy should continue to remain readily available, given the inverse correlation between operative interval and recovery.

Haematoma and abscess after neuraxial anaesthesia: a review of 647 cases

“…Patients with milder symptomatology are both more likely to recover fully, and more likely to be treated conservatively. 26 Furthermore, some patients had spontaneous recovery, that is, during the diagnostic process or while waiting for decompressive surgery. Consequently, after correcting for the severity of neurological deficit by the time of diagnosis and when excluding patients with spontaneous recovery, neurological outcome was similar in reports using each of the two different treatment strategies.…”

Safety of spinal anesthesia in thrombocytopenic patients: are there lessons to be learnt from oncology?

“…What they do tell is that SH does occur at even normal levels of platelet count, and the risk is not zero. Indeed, spontaneous spinal hematoma in the absence of hemostatic deficiency or neuraxial instrumentation also rarely occurs 19. Thus, although the lower limits of the risk CIs derived statistically start from zero, we believe practically, one must acknowledge that there is a baseline risk of SH after SA even in patients without hemostatic defects, which is 8:260 000 (risk 0.00003; 95% CI 0.00001 to 0.00006), according to a Swedish study 20.…”

“…In a recent literature review on spontaneous SH, the mean age of 71 patients was 53.2 years (SD 23) 19. Of the six SHs that occurred at those authors’ institutions, two adults were on aspirin, two adults were on warfarin and one adult was not on any antiplatelet or anticoagulant drug; one patient was an 11-year-old otherwise healthy girl whose diagnosis was made after she complained of headache and who recovered without intervention 19. In contrast, most of the series6–11 reported (table 1) are on children and adolescents (total n=13 685).…”

Hemiparesis in spontaneous spinal epidural haematoma: a potential stroke imitator

“…Non-operative management is feasible if spontaneous recovery is seen or if the neurological deficits are mild 1 3 25. However, haematoma evacuation is preferred in patients with profound deficit as there is inverse correlation between time to surgery and recovery 1. A study by Shin et al with a series of 14 patients showed that 84% of patients recovered if operated within 12 hours while only 64% of them recovered if operated between 12 and 24 hours.…”