The mr finding of an acute spinal epidural hematoma seh can mimic epidural neoplastic or inflam. Trauma or other injury to your head can cause your brain to bounce. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. Cervical spine epidural hematomas cseh are rare, and surgical intervention is typically required. Spinal epidural hematoma is a rare but serious neurological complication of neuraxial anesthesia. Spinal subdural hematoma sdh is a rare and potentially lifethreatening condition associated with trauma, lumbar puncture, hemorrhagic disorder, anticoagulant therapy, spinal surgery, tumor, vascular malformations, and spinal or epidural anesthesia. Spinal epidural haematoma is usually diagnosed based on the acute. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinalepidural anesthetic.
Spontaneous spinal epidural hematoma sseh is a rare but highly. Consider these risks when scheduling patients for spinal procedures. Article acute spinal epidural hematoma applied radiology. Each of these three structures merges with the inner aspect of the dura mater. Spontaneous spinal epidural hematoma sseh is a rare diagnosis. One known risk factor is anticoagulation medication. At the time of the examination, the mr scan provided no indication of myelopathy. Epidural hematomas after the implantation of thoracic.
May 29, 2015 a spinal hematoma or epidural hematoma is a collection of blood that presses on the spinal cord or nearby nerves. A spinal subdural or epidural hematoma is an accumulation of blood in the subdural or epidural space that can mechanically compress the spinal cord. Spontaneous spinal epidural hematoma sseh represents 0. The idiopathic forms are considered not to be attributed to any specific risk factors. Epidural hematoma is the accumulation of blood in the space between dura and bone in the cranial or spinal region. After the procedure, spinal subdural blood would have flowed into the spinal epidural space, resulting in a massive hematoma behind the spinal cord and hence its compression. This 3fold increase in the occurrence of an epidural hematoma when comparing small scs thoracic laminectomies with usually much larger scs thoracic laminectomies seems paradoxical. Spontaneous resolved cervical spine epidural hematoma. Pdf traumatic spinal epidural hematoma is rare in children. Incidence of epidural hematoma, infection, and neurologic. Much of what is known about epidural hematomas comes from case reports. Like acute spinal epidural hematomas, these asshs can expand rapidly and extend over many spinal segments, caus ing sudden spinal cord andor cauda equina compression 119. Spinal epidural hematoma after pain control procedure. Idiopathic thoracic spontaneous spinal epidural hematoma.
Most epidural hematomas are spontaneous and idiopathic. A 33yearold male patient experienced temporary sensory loss and weakness in the right lower extremity one month prior to admission. Traumatic lumbar spinal subdural hematoma sciencedirect. Spontaneous spinal epidural hematoma exerting pressure on the spinal cord. Experience in the surgical management of spontaneous spinal. It should combine the onset time to analyze the mr signs of hematoma. This is followed by the onset of progressive neurological symptoms. The combined spinal epidural cse technique, a comparatively new anesthetic choice, includes an initial subarachnoid injection followed by epidural catheter placement and subsequent administration of epidural. Spinal epidural hematoma is a rare, but potentially devastating, consequence of accessing the epidural space for anesthesia or interventional pain procedures.
Thoracic part of vertebral column is more complex combining narrow. This patient had a spinal epidural hematoma, which is defined as a spontaneous collection of blood in the spinal epidural space. Neonatal intensive care will combine their annual congress with the c. The posterior fossa is a rare location for traumatic injury, in general, including edh epidural hemorrhage epidural hematoma, extradural hemorrhage, or hematoma bleeding outside the outermost layer of the dural mater, which is thus stripped away from the inner table of the extradrual or spinal canal. The incidence is estimated at 0,1 per 100,000 per year in the general population 1. Ctguided percutaneous intraspinal needle aspiration for. Spinal epidural hematoma epidural or spinal hematomas have occurred in patients treated with xarelto who are receiving neuraxial anesthesia or undergoing spinal puncture. Twelve of these cases resulted from spinal surgery, seven from epidural catheters, four from vascular lesions, three from anticoagulation medications, two. Spinal epidural hematoma seh represents the most frequent entity of acute or chronic spinal bleeding. Spinal epidural hematoma after spinal cord stimulator trial lead placement in a patient taking aspirin asokumar buvanendran, md, and adam c.
Epidural hematoma definition and patient education. The classical clinical picture is that of acute onset of severe, often radiating, back pain followed by signs and symptoms of a rapidly evolving nerve root andor spinal cord compression. Since its introduction through safe motherhood initiative, little is known about its existence in. Spontaneous and idiopathic chronic spinal epidural hematoma.
Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries and 515% of patients with fatal head injuries. Among other factors, spine surgeons must weigh the risk of a symptomatic postoperative epidural hematoma against the benefit of dvtpe prevention when deciding. Intracranial hypotension secondary to spinal csf leak. Hematoma, epidural, spinal definition of hematoma, epidural. Spontaneous spinal epidural hematoma from rivaroxaban the. Treatment is generally by urgent surgery in the form of a craniotomy or burr hole. Jul 08, 2015 extending through the dorsal epidural space of the thoracic and upper lumbar spinal region, there is a t1, t2, and stir hyperintense collection, compatible with an acute hematoma, partially. When this condition occurs in the spine it is known as a spinal epidural hematoma.
Note that false localizing signs on imaging at c12 and the cervicothoracic junction are common and may lead to misdirected treatment. It is isointense on the t1weighted scan and slightly bright on the t2weighted scan. Delay in treating spinal hematoma can lead to paralysis or. Spontaneous spinal epidural hematoma mimicking transient isc. The risk of these events is increased by the use of indwelling epidural catheters for administration of analgesia or by the concomitant use of drugs affecting hemostasis such as non steroidal anti. Sep 30, 2010 spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Driving after an epidural steroid injection without sedation. Mri done on the 7th day from symptom onset reveals posterior epidural region collection of the cervical spinal canal. Spinal epidural hematoma is a collection of blood in the potential space between the dura and the bone, along the spinal canal. Spinal epidural hematoma seh is a relatively rare clinical entity that.
Doblar and schumacher41 report one case of spontaneous epidural hematoma, as well as six other reports of spontaneous epidural hematoma during pregnancy, all with some neurologic symptoms. Diagnosis is by mri or, if not immediately available, by ct myelography. A 28yearold man presented with acute chest pain for 1 hour. Epidural abscess spinal epidural hematoma spinal etiology. Bleeding into the epidural space can be caused by an epidural injection, back trauma, lumbar puncture, anticoagulant medication, traumatic fall or a catastrophic injury or accident. Spinal epidural hematoma after spinal cord stimulator.
Some of the most likely causes of an epidural hematoma include. Abram, md injection of suspensions of corticosteroids into or adjacent to the spinal canal is performed on a. The risk of these events is increased by the use of indwelling epidural catheters for administration of analgesia or by the concomitant use of drugs affecting. Contrast enhancement patterns of acute spinal epidural hematomas. There are few reported cases of an epidural spinal hematoma following interventional pain procedures. It may result in paraplegia, quadriplegia and even death.
Spinal epidural hematomas edh are a rare spinal pathology which can result in serious morbidity with delayed or nontreatment. There were four 4 cases with posterior epidural abscesses in the thoracic or lumbar spine and two 2 with posterior epidural hematomas in the lumbar spine. A diagnosis of acute, cervical, spontaneous spinal epidural hematoma was made in two patients by combining clinical signs and myelographic findings. Read more about symptoms, diagnosis, treatment, complications, causes and prognosis. Bleeding may also occur secondary to trauma, spinal surgery, angioma, vascular malformation or coagulopathies, most particularly anticoagulant therapy. Spinal epidural hematoma epidural avm in collaboration with donato pacione, md the classical teaching holds that isolated spinal epidural hematomas are venous hemorrhages, and no angiographic investigation is warranted. A 44yearold female with cervical myelopathy presented with a mild quadriparesis following manipulation by a. Conservative treatment of spontaneous spinal epidural. It explains the causes, symptoms and treatment of the headache. The lesion was noticeably exerting pressure on the spinal cord. The goal of the present investigation was to compare the doublesegment and the needlethroughneedle techniques for combined spinal and epidural. Male and martin 42 and kitching and rice 43 reported spontaneous puerperal spinal epidural abscesses without epidural anesthesia.
The risk of spinal hematoma with subsequent sensorimotor impairment may be mitigated by transforaminal access in accordance with clinical practice guidelines 1,2. However, spinal catheters are expensive, and the risk of confusing the spinal catheter with an epidural catheter may restrict their use in postoperative pain management. Spinal epidural hematoma can complicate procedures that involve a spinal dural puncture, usually in patients with approach to neck stiffness in children view in chinese sternocleidomastoid muscle and the chin towards the muscle in patients with atlantoaxial subluxation. Clinical features epidural compression syndromes table. Spontaneous spinal epidural hematoma in two toddlers. The condition occurs in one to four percent of head injuries. Owing to a rich vascular supply, spinal epidural hematoma is the most common intraspinal hematoma but remains a rare condition, with an estimated incidence of 0. The safe use of epidural steroid injections anesthesia. In the cervical spine, patients can present with neurological deficits ranging from focal cervical radiculopathy to complete quadriplegia.
All patients had minimal to mild neurologic deficit. Results in the four cases with epidural abscesses, ctguided aspiration showed purulent. In the hallmark of epidural hematoma, people may regain consciousness and appear completely normal during what is called a lucid interval, only to descend suddenly and rapidly into unconsciousness later. Acute spinal subdural hematoma assh is an uncommonly recognized condition that if left untreated can result in severe irreversible neu rologic deficits 17. Spontaneous spinal epidural hematoma is a rare neurologic emergency with accumulation of blood in the spinal epidural space without obvious traumatic or iatrogenic cause. The images produced by the mr scan gave rise to suspicion of a spontaneous spinal epidural hematoma.
Hyperintense on t2, isointense on t1 rim enhancement on gadolinium injection and blooming on gradient echo sequences. We report a case of a spinal epidural hematoma in a patient with no known risk factors e. The causes are diverse, including epidural hematoma, epidural abscess, direct cord trauma, spinal infarction, and neurotoxicity by accidental subarachnoid injection or chemical contamination. The spontaneous spinal epidural hematoma sseh also referred to as idiopathic spinal epidural hematoma is a rarely occurring condition. Epidural hematomas are the direct result of physical trauma to the head.
Epidural hematoma epidural hematoma clinical presentation. Operative treatment of spontaneous spinal epidural. An epidural hematoma occurs when a mass of blood forms in the space between your skull and the protective covering of your brain. Hemorrhage is an uncommon but documented adverse reaction when using lmwh.
Pdf traumatic spinal epidural hematomaunusual cause of. The patient was admitted to a private clinic with a threeday history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the guillainbarre syndrome gbs. Jan 09, 2018 epidural hematoma ie, accumulation of blood in the potential space between dura and bone may be intracranial edh or spinal sedh see the image below. Spinal epidural hematoma seh is a very rare cause of acute spinal cord compression and is estimated to occur in approximately 0. Spinal epidural hematoma following epidural anesthesia.
Enoxaparin sodium is a low molecular weight heparin lmwh for use in preventing deep venous thrombosis in patients undergoing total hip arthroplasty and total knee arthroplasty. Request pdf experience in the surgical management of spontaneous spinal epidural hematoma spontaneous spinal epidural hematoma. The safe use of epidural steroid injections stephen e. The incidence of epidural hematoma in nonscs procedures is 0. Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries. Patients who endure periods of extended recumbency and limited mobility after major operative spinal interventions may be at increased risk of thromboembolic disease. This lucid interval, which depends on the extent of the injury, is a key to diagnosing an epidural hematoma. In the literature, sseh is defined either as a spinal epidural hematoma seh occurring in the absence of trauma or iatrogenic. Spinal epidural hematoma after epidural anesthesia in a. Review the current literature regarding spontaneous spinal epidural hematomas ssehs and report on the known risk factors, evaluation, and. Contrast enhancement patterns of acute spinal epidural. Spinal epidural hematoma is bleeding into the epidural space in the spine. Based upon pathogenesis, seh can be classified as idiopathic, spontaneous, and secondary.
Note the large extradural lesion which compresses the thecal sac from l2 through s1. Here, we present the rare case of a cseh resulting from chiropractic manipulation successfully treated conservatively. The incidence of spinal epidural hematomas seh is 0. Background the question of whether to allow patients to drive immediately following an epidural steroid injection esi is a dilemma that is not directly addressed by clinical. Acute spinal epidural hematoma may occur spontaneously with no apparent or only trivial antecedent cause. Thirty patients were treated surgically for spinal epidural hematoma seh. Typically, spinal gnathostomiasis is presented as radiculomyelitis. The patient was admitted to a private clinic with a threeday history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the guillainbarre. Spinal epidural hematoma can occur with substantial trauma to a normal spine, particularly in a newborn after breech delivery, or with mild trauma to the spine in a patient with a bleeding diathesis, with a spinal epidural hemangioma, or. Spinal epidural hematoma seh is a rare but important cause of spinal cord compression. Epidural anaesthesia and spinal haematoma hinnerk wulf md purpose.
Spinal cord compression nontraumatic cauda equina syndrome. A metaanalysis of spinal hematomas showed that 75% are epidural in origin. When epidural blood patching is unsuccessful or if symptoms recur, spinal imaging findings help to guide further treatment. Spinal epidural hematoma seh is an uncommon condition usually characterized by acute back pain. Pdf combined spinal epidural anesthesia and analgesia. Epidural hematoma unrelated to combined spinalepidural.
Spontaneous spinal epidural hematoma sseh is a rare disease that can lead to the acute onset of severe neurological deficits, 1 requiring early. Epidural hematoma ie, accumulation of blood in the potential space between dura and bone may be intracranial edh or spinal sedh see the image below. The causes of seh range from iatrogenic to idiopathic. Prompt diagnosis and emergent decompressive surgical management. They are typically considered a surgical emergency. Haematoma formation in the spinal canal due to epidural anaesthesia is a very rare but serious complication.
The safety of spinal and epidural anesthesia has been well established. Pdf delayed postoperative spinal epidural hematomas. Spontaneous spinal epidural hematoma sseh is a rare condition. Epidural hematoma after routine epidural steroid injection.
Usually, diagnosis of an seh can be made without difficulty on the basis of specific signal intensity changes and morphologic findings on mr images. In recent years, regional anesthesia techniques for surgery, obstetrics, and postoperative pain management have been used with increasing frequency. In cse, it is possible to administer an intraspinal opioid and take advantage of the long duration of action compared to epidural administration 21,41. Spinal epidural hematoma radiology reference article. Epidural hematoma with spinal cord puncture wound youtube. A report of two cases fengchi chang, jiingfeng lirng, shingsu chen, chaobao luo, wanyou guo, michael mu huo teng, and chengyen chang summary. These hematomas may result in longterm or permanent paralysis. Spontaneous spinal epidural hematoma sseh is a rare emergent condition. Spinal subdural or epidural hematoma neurologic disorders.