特発性脊髄硬膜外血腫の急性期診断と治療方針に関する臨床的検討(Emergency diagnosis and treatment of spontaneous spinal epidural hematoma)

Abstract

要旨【目的】特発性脊髄硬膜外血腫は，神経学的に緊急を要する比較的稀な疾患であり，救急現場で対応に苦慮することも多い。急性期の臨床的特徴を明らかにすることにより早期診断・治療の一助となることを目的とし，当院で経験した本症を急性期の臨床判断に焦点を当てて検討した。【対象】2007年1月から2012年10月までの期間に新潟市民病院に緊急入院となった特発性脊髄硬膜外血腫27例について後方視的に調査した。【結果】対象は年齢56～88歳（中央値70歳），男性12例，女性15例であった。全例で頸部や背部の急激な疼痛で発症していた。発症後ただちに当院救急外来を受診し来院時の血圧が確認できた9人のうち7名は血圧高値を示した。22例で疼痛発現後に運動麻痺を来したが，4例は神経症状を認めず疼痛のみであった。初療医によって遅延なく診断がなされたのは15例であった。全例MRIで確定診断され，血腫形成部位は頸椎が17例と最も多かった。治療については，重力に抗することができない高度の筋力低下を認めた15例は外科的治療を選択し，14例で麻痺の改善を認めた。改善を認めなかった1例は，手術までに12時間以上経過した術前完全麻痺の症例であった。【結語】突然の頸部もしくは背部痛を訴えた場合，明らかな運動麻痺を認めなくても，本疾患を念頭に置く必要がある。麻痺症状が高度である場合，早期に外科的治療を行うことで神経学的予後の改善が期待できる。

Two Patients with Spontaneous Spinal Epidural Hematoma Carrying a Good Prognosis without Surgical Operations

“…After 24 h, hematoma of SSEH is delineated as a hyper-intensity mass on T1- and T2-weighted MRI images [ 5 , 12 , 14 ], and then the lesion was delineated as a low-intensity mass on T1- and T2-weighted MRI images [ 5 , 12 , 14 ]. MRI findings in our patients were consistent with those of SSEH in the acute stage within the first 24 h [ 1 , 3 , 4 , 8 , 13 , 14 , 15 ]. The diagnosis in our patients was SSEH, based on the MRI findings and the absence of traumatic or iatrogenic experiences in their clinical courses; however, the vertebrae levels of the lesions were inconsistent with the characteristics of SSEH [ 2 , 5 , 6 , 8 , 10 , 13 ].…”

“…The most common site of hemorrhage in SSEH is the posterior epidural space at the cervicothoracic level (C5 to Th2) and the thoracolumbar level (Th10 to L2) [ 2 , 5 , 6 , 8 , 10 , 13 ]. Hematoma of SSEH is delineated as an iso-intensity mass on T1-weighted MRI images and a hyper-intensity mass with inside heterogeneity (hypointense-foci) on T2-weighted MRI images in the acute stage within the first 24 h [ 1 , 3 , 4 , 8 , 13 , 14 , 15 ]. After 24 h, hematoma of SSEH is delineated as a hyper-intensity mass on T1- and T2-weighted MRI images [ 5 , 12 , 14 ], and then the lesion was delineated as a low-intensity mass on T1- and T2-weighted MRI images [ 5 , 12 , 14 ].…”

“…Back pain was present in both of our patients ( Table 1 ), which was consistent with the characteristic onset of SSEH [ 1 , 2 , 4 , 5 , 6 , 8 , 10 , 12 , 13 ]. Rapidly progressive neurological deficits are caused by an accumulation of hematoma within the epidural space [ 1 , 2 , 4 , 5 , 6 , 8 , 15 ]. The location of hematoma shows a tendency to have an uneven distribution in the posterior part of the epidural space [ 6 , 9 , 12 ].…”

“…The location of hematoma shows a tendency to have an uneven distribution in the posterior part of the epidural space [ 6 , 9 , 12 ]. Accordingly, clinical features of SSEH depend on the site of hematoma [ 9 , 12 ] and include radiculopathy or myelopathy, or both, which are associated with various distributions of palsy of the extremities [ 2 , 6 , 15 , 16 ]. Patients without palsy of the extremities have also been reported [ 16 ].…”

“…The posterior part of the internal vertebral venous plexus is considered to be the most likely point of rupture in SSEH [ 1 , 5 , 6 , 7 , 8 , 12 , 14 ]. The anterior part of the internal vertebral venous plexus is thought to be hard to rupture compared with the posterior part because the anterior part clings to the posterior longitudinal ligaments [ 1 , 4 , 14 , 15 ]. Hematomas in our patients were located posteriorly to the spinal cord, which was consistent with the characteristics of SSEH [ 1 , 5 , 6 , 7 , 8 , 12 , 14 ] and was probably caused by the rupture of the internal vertebral venous plexus.…”