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Dang R, Issagholian L, Schmidt T, Raoufi P, Neeki CC, Neeki MM. Management of traumatic cervical epidural hematoma in patients on Xa-inhibitors: a case report and review of the literature. J Med Case Rep 2023; 17:488. [PMID: 37936238 PMCID: PMC10629042 DOI: 10.1186/s13256-023-04069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/05/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This unique case of traumatic CEH represents an even smaller subset of these cases. Management varies by symptom presentation, mechanism of injury, and other contraindications. CASE PRESENTATION This case presents a 32 year old African American female on an oral anticoagulant sustaining traumatic cervical hematoma after a motor vehicle collision. Patient complained of neck, abdominal, and back pain. Imaging revealed a cervical spinal hematoma at the level of C3-C6. This case discusses the management of CEH for the general population and in the setting of anticoagulation. CONCLUSION Management of each case of CEH must be carefully considered and tailored based on their symptom presentation and progression of disease. As the use of anticoagulation including factor Xa inhibitors becomes more prevalent, there is greater need to understand the detailed pathophysiological aspect of the injuries. Targeted reversal agents such as Prothrombin Concentrate can be used for conservative treatment. Adjunct testing such as thromboelastogram can be used to help guide management.
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Affiliation(s)
- Robert Dang
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Leo Issagholian
- California University of Science and Medicine, Colton, CA, USA
| | - Tegan Schmidt
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Pasha Raoufi
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Cameron C Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA
| | - Michael M Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA.
- California University of Science and Medicine, Colton, CA, USA.
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA, USA.
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Tu PH, Liu ZH, Yeap MC, Liu YT, Li YC, Huang YC, Lin TM, Chen CC. Spinal cord injury and spinal fracture in patients with ankylosing spondylitis. BMC Emerg Med 2022; 22:73. [PMID: 35501709 PMCID: PMC9063196 DOI: 10.1186/s12873-022-00635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Spinal cord injury (SCI) and spinal fracture are major complications in patients with ankylosing spondylitis (AS) who sustain spinal trauma. The purpose of this study was to investigate the incidence, predictors, and sequelae of spinal trauma in patients with AS. Methods This retrospective study included patients with AS who were admitted for spinal trauma between January 1, 2006, and June 30, 2016. The study compared clinical outcomes of patients between group 1: SCI alone, group 2: spinal fracture alone (no SCI), and group 3: both SCI and spinal fracture. Results Of the 6285 patients with AS admitted during the retrospective study period, only 105 suffered from spinal trauma and were enrolled in the study. Case number in group 1, 2, and 3 was 11(10.48%), 45(42.85%), and 49(46.67%), respectively. Among the patients with spinal fractures, 52.1% had SCI. Bamboo spine was significantly more prevalent in the fracture group than in the nonfracture group (78.7% vs. 36.4%; P = 0.006). Patients with SCI had more instances of subluxation or dislocation (48.3% vs. 8.9%; P < 0.001) and more cases of spinal epidural hematoma (SEH; 21.7% vs. 2.2%; P = 0.003) than patients without SCI. The rate of delayed diagnosis for spinal fracture was 31.4%, with one-third of patients developing delayed SCI. Among the patients with incomplete SCI, 58.3% achieved neurological improvement after treatment (P = 0.004). Conclusions Patients with AS and bamboo spine at radiograph had a higher rate of spinal fracture, which may be an important factor in SCI in patients with AS. Spinal fractures involving the C3–C7 region, subluxation or dislocation, severe spinal fracture, and SEH were found to be predictive of SCI, and SCI in patients with AS resulted in higher mortality and complication rates.
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Affiliation(s)
- Po-Hsun Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Mun-Chun Yeap
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Tse Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Ying-Ching Li
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yin-Cheng Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Tzu-Min Lin
- Department of Internal Medicine, Division of Rheumatology, Immunology and Allergy, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Internal Medicine, Division of Allergy, Immunology and Rheumatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan.
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Liu H, Zhang T, Qu T, Yang CW, Li SK. Spinal epidural hematoma after spinal manipulation therapy: Report of three cases and a literature review. World J Clin Cases 2021; 9:6501-6509. [PMID: 34435018 PMCID: PMC8362556 DOI: 10.12998/wjcc.v9.i22.6501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spinal manipulation therapy (SMT) has been widely used worldwide to treat musculoskeletal diseases, but it can cause serious adverse events. Spinal epidural hematoma (SEH) caused by SMT is a rare emergency that can cause neurological dysfunction. We herein report three cases of SEH after SMT.
CASE SUMMARY The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT. Her symptoms persisted after 3 d of conservative treatment, and she was admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated an SEH, extending from C6 to C7. The second case was a 55-year-old man with sudden back pain 1 d after SMT, numbness in both lower limbs, an inability to stand or walk, and difficulty urinating. MRI revealed an SEH, extending from T1 to T3. The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT. He was unable to stand or walk and experienced mild back pain. MRI revealed an SEH, extending from T1 to T2. All three patients underwent surgery after failed conservative treatment. The three cases recovered to ASIA grade E on day 5, 1 wk, and day 10 after surgery, respectively. All patients returned to normal after 3 mo of follow-up.
CONCLUSION SEH caused by SMT is very rare, and the condition of each patient should be evaluated in full detail before operation. SEH should be diagnosed immediately and actively treated by surgery.
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Affiliation(s)
- Hua Liu
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Tao Zhang
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Tao Qu
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Cheng-Wei Yang
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
| | - Song-Kai Li
- Department of Spine Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army, Lanzhou 730050, Gansu Province, China
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Chia KJ, Lin LH, Sung MT, Su TM, Huang JF, Lee HL, Sung WW, Lee TH. Acute spontaneous thoracic epidural hematoma associated with intraspinal lymphangioma: A case report. World J Clin Cases 2021; 9:3411-3417. [PMID: 34002152 PMCID: PMC8107886 DOI: 10.12998/wjcc.v9.i14.3411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/24/2021] [Accepted: 03/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous spinal epidural hematoma is a rare neurosurgical emergency. CASE SUMMARY A 53-year-old healthy woman suffered from complete paraplegia in both legs and loss of all sensation below the xiphoid process. She was diagnosed as acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma. The primary lab survey showed all within normal limits. Presence of a posteriorly epidural space-occupying lesion at the T4-T8 level of the spinal canal was confirmed on magnetic resonance imaging. A decompressive laminectomy was performed from the T4 to T7 levels at the sixth hour following abrupt onset of complete paraplegia. The lesion was confirmed as lymphangioma. This patient recovered well within one month. CONCLUSION This study reports a case of acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma with well recovery after surgical intervention.
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Affiliation(s)
- Kai-Jay Chia
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Li-Han Lin
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Ming-Tse Sung
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Tsung-Ming Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Jin-Fu Huang
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Hsiang-Lin Lee
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Wen-Wei Sung
- Department of Urology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Tsung-Han Lee
- Division of Neurosurgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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Konomi T, Suda K, Ozaki M, Harmon SM, Komatsu M, Iimoto S, Tsuji O, Minami A, Takahata M, Iwasaki N, Matsumoto M, Nakamura M. Predictive factors for irreversible motor paralysis following cervical spinal cord injury. Spinal Cord 2021; 59:554-562. [PMID: 32632174 DOI: 10.1038/s41393-020-0513-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective observational study. OBJECTIVES To elucidate predictive clinical factors associated with irreversible complete motor paralysis following traumatic cervical spinal cord injury (CSCI). SETTING Hokkaido Spinal Cord Injury Center, Japan. METHODS A consecutive series of 447 traumatic CSCI persons were eligible for this study. Individuals with complete motor paralysis at admission were selected and divided into two groups according to the motor functional outcomes at discharge. Initial findings in magnetic resonance imaging (MRI) and other clinical factors that could affect functional outcomes were compared between two groups of participants: those with and those without motor recovery below the level of injury at the time of discharge. RESULTS Of the 73 consecutive participants with total motor paralysis at initial examination, 28 showed some recovery of motor function, whereas 45 remained complete motor paralysis at discharge, respectively. Multivariate logistic regression analysis showed that the presence of intramedullary hemorrhage manifested as a confined low intensity changes in diffuse high-intensity area and more than 50% of cord compression on MRI were significant predictors of irreversible complete motor paralysis (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 1.2-58.2 and OR: 14.4; 95% CI: 2.5-82.8, respectively). CONCLUSION The presence of intramedullary hemorrhage and/or severe cord compression on initial MRI were closely associated with irreversible paralysis in persons with motor complete paralysis following CSCI. Conversely, subjects with a negligible potential for recovery could be identified by referring to these negative findings.
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Affiliation(s)
- Tsunehiko Konomi
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan.
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, 2-37-1 Gakuen, Musashimurayama, Tokyo, 208-0011, Japan.
| | - Kota Suda
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiro Ozaki
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi, Yokohama, Kanagawa, 230-8765, Japan
| | - Satoko Matsumoto Harmon
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Miki Komatsu
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Seiji Iimoto
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Ehime Prefectural Central Hospital, 83 Kasugamachi, Matsuyama, Ehime, 790-0024, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Akio Minami
- Department of Orthopaedic Surgery, Hokkaido Spinal Cord Injury Center, 3-1 Higashi 4 Minami 1, Bibai, Hokkaido, 072-0015, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-0808, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Hokkaido University, Kita 8, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-0808, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
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Agrawal A, V. UMR, Brinda K, Moscote-Salazar LR, Dhanireddy K. Posttraumatic Acute Spinal Epidural Hematoma of the Dorsolumbar Region. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractIn spite of the relative common occurrence of spinal injuries, spinal epidural hematomas (SEHs) are rare lesions. Depending on the onset, site, size, and presence of neurological deficits, they can be treated conservatively or surgically. In the presented article, we report an uncommon case of posttraumatic dorsolumbar SEH and discuss the characteristic magnetic resonance imaging (MRI) imaging findings of epidural fat in the cases of traumatic spinal hematomas.
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Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
| | - Uma Maheshwara Reddy V.
- Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
| | - Kuraparthy Brinda
- Department of Anesthesia, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
| | - Luis R. Moscote-Salazar
- Faculty of Medicine, Neurosurgeon-Critical Care, Center for Biomedical Research (CIB), University of Cartagena, Cartagena de Indias, Bolivar, Colombia
| | - Keerthana Dhanireddy
- Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
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7
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Vashisht S, Dagar A, Kumar V, Dhatt SS. Post-traumatic thoracolumbar spinal epidural haematoma in a child: a rare clinical entity. BMJ Case Rep 2019; 12:12/12/e232055. [PMID: 31801780 DOI: 10.1136/bcr-2019-232055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Post-traumatic spinal epidural haematoma (SEH) is a rare clinical entity in children. We are reporting the case of an 8-year-old child who presented with thoracolumbar SEH with neurological deficit. MRI confirmed SEH without bony disruption. Emergency evacuation of haematoma was done. There was an improvement in neurological status after removal of haematoma. Diagnosis of this rare condition is tricky in children owing to variable presenting symptoms, especially in an early stage with subtle neurological changes. There should be high clinical suspicion in children with atypical symptoms, and MRI should be done to confirm the diagnosis. Patients with acute neurological deficit should undergo urgent operative decompression. Conservative treatment has a limited role. Patients may be considered for non-operative management if they have medical contraindications, coagulation dysfunction or a small SEH without neurological deficit. These patients require serial MRI monitoring.
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Affiliation(s)
- Saurabh Vashisht
- Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Dagar
- Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Kumar
- Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sarvdeep Singh Dhatt
- Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Low SYY, Ker JR, Ng LP, Seow WT, Low DCY. Thoracic epidural haematoma after spinal manipulation treatment. Childs Nerv Syst 2019; 35:735-737. [PMID: 30903282 DOI: 10.1007/s00381-019-04122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore.
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore.
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore.
| | - Justin R Ker
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
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Massage-induced spinal epidural hematoma presenting with delayed paraplegia. Am J Emerg Med 2019; 37:797.e1-797.e4. [PMID: 30691861 DOI: 10.1016/j.ajem.2019.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury. OBJECTIVE We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia. CASE REPORT A 20-year-old man presented with bilateral lower extremity weakness and numbness 3 h prior to presentation. 3 days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flow or AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma. CONCLUSION Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome.
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Teunissen FR, Verbeek BM, Cha TD, Schwab JH. Spinal cord injury after traumatic spine fracture in patients with ankylosing spinal disorders. J Neurosurg Spine 2017; 27:709-716. [DOI: 10.3171/2017.5.spine1722] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVESpinal cord injury (SCI) is a major complication of spinal fractures in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). Due to the uncommon nature of these conditions, existing literature consists of relatively small case series without detailed neurological data. This study aims to investigate the incidence, predictors, and sequelae of SCI in patients with a traumatic fracture of the ankylosed spine.METHODSThe study included all patients older than 18 years of age with AS or DISH who presented to two affiliated tertiary care centers between January 1, 1990, and January 1, 2016, and had a traumatic fracture of the spine. Factors associated with SCI after traumatic fracture were compared using Fisher’s exact tests. Logistic regression was used for the analysis of predictive factors for SCI. For the comparison of probability of survival between patients with and without SCI, Kaplan-Meier methodology was used.RESULTSOne hundred seventy-two patients with a traumatic fracture of an ankylosed spine were included. Fifty-seven patients (34.1%) had an SCI associated with the fracture. The cervical spine was the most fractured region for patients both with (77.2%) and without (51.4%) SCI. A cervical fracture (odds ratio [OR] 2.70, p = 0.024) and a spinal epidural hematoma (SEH) after fracture (OR 2.69, p = 0.013) were predictive of SCI. Eleven patients (19.3%) with SCI had delayed SCI (range 8–230 days). Of 44 patients with SCI and sufficient follow-up, 20 (45.5%) had neurological improvement after treatment. Early and late complication rates were significantly higher (p = 0.001 and p = 0.004) and hospital stay was significantly longer (p = 0.001) in patients with SCI. The probability of survival was significantly lower in the SCI group compared with the non-SCI group (p = 0.006).CONCLUSIONSThe incidence of SCI was high after fracture of the spine in patients with AS and DISH. Predictive factors for SCI after fracture were a fracture in the cervical spine and an SEH following fracture. One-fifth of the patients with SCI had delayed SCI. Patients with SCI had more complications, a longer hospital stay, and a lower probability of survival. Less than half of the patients with SCI showed neurological improvement.
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11
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Ricart PA, Verma R, Fineberg SJ, Fink KY, Lucas PA, Lo Y, Asprinio DE, Amorosa LF. Post-traumatic cervical spine epidural hematoma: Incidence and risk factors. Injury 2017; 48:2529-2533. [PMID: 28935352 DOI: 10.1016/j.injury.2017.08.060] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/20/2017] [Accepted: 08/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The incidence and risk factors for post-traumatic cervical epidural hematoma are not well described in the current literature. Our aim was to determine the incidence and associated risk factors for post-traumatic cervical spine epidural hematoma (SEH). METHODS We performed a retrospective review of our institution's prospectively collected data submitted to the state trauma registry, using ICD-9 codes, for all patients activated as a trauma with cervical spine injuries, between the years 2010 and 2014. Patients with MRI available were classified based on the presence of cervical epidural hematoma (CEH) or no hematoma (NEH). For our second analysis, we classified patients with cord compression associated with an epidural hematoma (CC) and no cord compression (NCC). Potential risk factors evaluated included: INR, PTT, albumin and platelets levels, radiographic findings of Ankylosing Spondylitis (AS), and ISS. No conflicts of interest exist and/or funding was used for this study. RESULTS 497 out of 1810 trauma activations met our inclusion criteria. 46 patients (2.5%) were found to have a post-traumatic cervical SEH (CEH). Of the CEH cohort, 76% were male, with 72% Caucasian, and a mean age of 55 years. 27 patients (5.4%) were found to have cervical cord compression at the level of the SEH. Of the CC arm, 78% were male, with 67% Caucasian, and a mean age of 56 years. A higher ISS and an elevated INR were found to be associated with epidural hematoma causing cord compression. CONCLUSIONS An incidence of 2.5% is reported for post-traumatic cervical spine epidural hematoma. Of these, 59% had associated spinal cord compression. Patients with a higher ISS and elevated INR levels are at a higher risk for developing this potentially devastating.
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Affiliation(s)
- Pedro A Ricart
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
| | - Ravi Verma
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Steven J Fineberg
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Kyle Y Fink
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Paul A Lucas
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Yungtai Lo
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - David E Asprinio
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Louis F Amorosa
- Department of Orthopaedic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA; Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
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12
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A study of predictors for hyponatraemia in patients with cervical spinal cord injury. Spinal Cord 2017; 56:84-89. [PMID: 28895577 DOI: 10.1038/sc.2017.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 07/18/2017] [Accepted: 07/24/2017] [Indexed: 01/30/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVES The objectives of the study were to investigate the predictors for hyponatraemia in patients with cervical spinal cord injuries (CSCIs) and to define the relationship between magnetic resonance imaging (MRI) scans and hyponatraemia. SETTING The study was carried out at The First Affiliated Hospital of Anhui Medical University. METHODS A total of 292 patients with CSCIs were retrospectively reviewed to determine the predictors of hyponatraemia. Fourteen variables were extracted from the medical records: age, sex, blood pressure (BP), tracheostomy, serum potassium, serum chloride, serum bicarbonate, serum albumin, intravenous fluid intake and urine volume for 24 h, haematocrit, haemoglobin, neurological assessment and four MRI signal patterns. Univariate and multivariate analyses were used to determine the effect of each variable on hyponatraemia. RESULTS Eighty-two of the 270 patients (30%) developed hyponatraemia. Univariate analyses indicated that the following variables were significant predictors of hyponatraemia: tracheostomy; the initial American Spinal Injury Association (ASIA) Impairment Scale (AIS) A assessment; and haemorrhage changes on T2-weighted MRI scans, and low BP. Multivariate regression analyses revealed two variables were significant predictors of hyponatraemia: haemorrhage changes on T2-weighted MRI scans and low BP. CONCLUSIONS Haemorrhage changes on MRI scans were closely associated with the onset of hyponatremia and could provide objective data for forecasting hyponatraemia in CSCI patients. Low BP was also a reasonable predictor of hyponatremia.
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Kumar Y, Hayashi D. Role of magnetic resonance imaging in acute spinal trauma: a pictorial review. BMC Musculoskelet Disord 2016; 17:310. [PMID: 27448661 PMCID: PMC4957861 DOI: 10.1186/s12891-016-1169-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/12/2016] [Indexed: 01/12/2023] Open
Abstract
Magnetic resonance imaging (MRI) has been playing an increasingly important role in the spinal trauma patients due to high sensitivity for detection of acute soft tissue and cord injuries. More and more patients are undergoing MRI for spinal trauma in the emergency settings, thus necessitating the interpreting physicians to be familiar with MRI findings in spinal trauma. In this pictorial review, we will first describe the normal anatomy of various ligamentous structures. Indications of MRI in spinal trauma as well as the role of MRI in diagnosing spinal cord and soft tissue injuries will then be discussed. Illustrated cases are mainly of cervical spine trauma, but thoracolumbar spine injuries are also included where appropriate in our review.
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Affiliation(s)
- Yogesh Kumar
- Department of Radiology, Bridgeport Hospital, Yale New Haven Health System, 267 Grant Street, Bridgeport, CT, 06610, USA
| | - Daichi Hayashi
- Department of Radiology, Bridgeport Hospital, Yale New Haven Health System, 267 Grant Street, Bridgeport, CT, 06610, USA. .,Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building, 3rd Floor, Boston, MA, 02118, USA.
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14
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Traumatic spinal epidural hematoma in a 1-year-old boy. Arch Pediatr 2016; 23:731-4. [DOI: 10.1016/j.arcped.2016.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/20/2015] [Accepted: 04/06/2016] [Indexed: 01/30/2023]
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Effective Steroid Treatment in Traumatic Cervical Spinal Epidural Hematoma Presenting with Delayed Tetraparesis: Two Case Reports and Literature Review. World Neurosurg 2016; 91:673.e5-9. [DOI: 10.1016/j.wneu.2016.04.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/08/2016] [Accepted: 04/12/2016] [Indexed: 01/30/2023]
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Babayev R, Ekşi MŞ. Spontaneous thoracic epidural hematoma: a case report and literature review. Childs Nerv Syst 2016; 32:181-7. [PMID: 26033378 DOI: 10.1007/s00381-015-2768-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 05/22/2015] [Indexed: 12/23/2022]
Abstract
Spinal epidural hematoma is a rare neurosurgical emergency in respect of motor and sensory loss. Identifiable reasons for spontaneous hemorrhage are vascular malformations and hemophilias. We presented a case of spontaneous epidural hematoma in an 18-year-old female patient who had motor and sensory deficits that had been present for 1 day. On MRI, there was spinal epidural hematoma posterior to the T2-T3 spinal cord. The hematoma was evacuated with T2 hemilaminectomy and T3 laminectomy. Patient recovered immediately after the surgery. Literature review depicted 112 pediatric cases (including the presented one) of spinal epidural hematoma. The female/male ratio is 1.1:2. Average age at presentation is 7.09 years. Clinical presentations include loss of strength, sensory disturbance, bowel and bladder disturbances, neck pain, back pain, leg pain, abdominal pain, meningismus, respiratory difficulty, irritability, gait instability, and torticollis. Most common spinal level was cervicothoracic spine. Time interval from symptom onset to clinical diagnosis varied from immediate to 18 months. Spinal epidural hematoma happened spontaneously in 71.8 % of the cases, and hemophilia was the leading disorder (58 %) in the cases with a definable disorder. Partial or complete recovery is possible after surgical interventions and factor supplementations.
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Affiliation(s)
- Rasim Babayev
- Department of Neurosurgery, National Center of Oncology, Baku, Azerbaijan
| | - Murat Şakir Ekşi
- Department of Orthopedic Surgery-Spine Center, University of California at San Francisco, 500 Parnassus Avenue MU320 West, San Francisco, CA, 94143-0728, USA.
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Huang M, Barber SM, Moisi M, Powell S, Rivera A, Zwillman M, Rose J. Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation. Cureus 2015; 7:e307. [PMID: 26430581 PMCID: PMC4578713 DOI: 10.7759/cureus.307] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.
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Affiliation(s)
- Meng Huang
- Department of Neurogurgery, Houston Methodist Neurological Institute
| | - Sean M Barber
- Department of Neurogurgery, Houston Methodist Neurological Institute
| | - Marc Moisi
- Neurosurgery, Swedish Neuroscience Institute
| | - Suzanne Powell
- Department of Pathology and Laboratory Medicine, Houston Methodist Hospital
| | - Andreana Rivera
- Department of Pathology and Laboratory Medicine, Houston Methodist Hospital
| | | | - James Rose
- Department of Neurosurgery, University Medical Center Brackenridge
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18
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Garg K, Satyarthee GD, Singla R, Sharma BS. Extensive long-segment cervicothoracic traumatic spinal epidural hematoma with avulsion of C7, C8, and T1 nerve roots. J Neurosci Rural Pract 2014; 5:414-6. [PMID: 25288853 PMCID: PMC4173248 DOI: 10.4103/0976-3147.140007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Traumatic spinal epidural hematoma (TSEH) is of rare clinical occurrence. We report a case of a young man with posttraumatic long-segment spinal epidural hematoma. Evacuation of the hematoma led to complete neurologic recovery in our patient. Our case highlights the importance of early diagnosis and prompt surgical intervention for the evacuation of hematoma in preservation or maximum recovery of neurologic function. Imaging findings, management options, and the relevant literature are reviewed.
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Affiliation(s)
- Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Raghav Singla
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Anterior spinal pseudomeningocele after C0-C2 traumatic injuries: role of the "dural transitional zone" in the etiopathogenesis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22 Suppl 6:S889-93. [PMID: 24061976 DOI: 10.1007/s00586-013-3029-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/08/2013] [Accepted: 09/08/2013] [Indexed: 01/30/2023]
Abstract
PURPOSE Spinal pseudomeningoceles (SPM) are extradural collections of CSF (cerebrospinal fluid); a frequent association with upper cervical injuries (UCI) has been observed. We propose a possible etiopathogenetic mechanism supporting the formation of cervical SPM based on some considerations. METHODS We present four cases of SPM. All patients sustained a severe UCI. Three patients were symptomatic with delayed and progressive clinical signs. RESULTS One patient was misinterpreted as epidural hematoma and operated on due to progressive signs with postoperative clinical improvement. The rest of patients were treated conservatively; spontaneous reduction of CSF collection occurred. From a radiological standpoint: (1) a line of demarcation separated the intradural cervical compartment from the anterior epidural space, (2) CSF epidural collection was never evident at C0-C2 level and extended from C2 downwards, and (3) shape of collection was similar to epidural hematomas suggesting a ball-valve mechanism. CONCLUSIONS The dural layer at C0-C2 level is adherent to the thick ligamentous apparatus, as opposed to the segments below where it is solely covered by the posterior longitudinal ligament. A "transitional zone" of dura exists between the C0-C2 region and subaxial segment of the cervical spine. This watershed area constitutes a point of minor resistance. Lacerations of the meningeal layers, caused by severe UCI at the "transitional zone", drain CSF into the anterior epidural space and form SPM.
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20
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Desai MJ, Dua S. Perineural hematoma following lumbar transforaminal steroid injection causing acute-on-chronic lumbar radiculopathy: a case report. Pain Pract 2013; 14:271-7. [PMID: 23464852 DOI: 10.1111/papr.12047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 01/02/2013] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Transforaminal epidural steroid injections (TFESI) are commonly performed for the treatment of lumbar herniated nucleus pulposus and lumbosacral radiculopathy. Although rare, documented complications including spinal cord infarction, paraparesis, epidural abscess, paraplegia, and epidural hematoma have been reported. Here, we present a case of perineural hematoma affecting the L4 nerve root resulting in progressive acute-on-chronic lumbar radiculopathy following TFESI. CASE REPORT A 72-year-old female presented with 3 months of low back and right anterior thigh pain. She subsequently underwent right L3 and L4 TFESI for physical examination findings concordant with radiographic right foraminal stenosis at L3-4 and L4-5 with L3-4 spondylolisthesis. Over the following week, the patient reported progressive right lower extremity weakness, worsening sensory loss, and ambulatory dysfunction. Examination revealed mild L3/4 myotomal weakness, sensory changes, and areflexia at the right patella. A gadolinium-enhanced MRI was ordered, which showed focal abnormal signal with involvement of the right L4-L5 neuroforamina and extending slightly far laterally, consistent with a small hematoma, affecting the L4 nerve root. Within 2 months, her strength and reflexes normalized and sensory loss diminished following medical management. DISCUSSION Although extremely rare, perineural or foraminal hematomas may occur as a serious complication of TFESI, even in the setting of a standardized procedure. Hematoma may cause worsening of symptoms in the acute and subacute phase following TFESI. Further investigation into the etiologies of such injuries is warranted and must be added to the considerations of pain physicians performing these procedures.
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Affiliation(s)
- Mehul J Desai
- The GW Spine & Pain Center, George Washington University Medical Center, Washington, District of Columbia, U.S.A
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21
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Abstract
Spontaneous spinal epidural hematoma (SSEH) has been reported as a rare condition especially in childhood. Because its symptoms are atypical, it is not easy to diagnose the onset of SSEH. However, with wider use of magnetic resonance imaging (MRI), several SSEH cases, especially not requiring surgical intervention, have been reported. We report on a 12-year-old boy who presented with a 5-day history of progressive pain in his back and extremities and numbness of his lower legs. An MRI of the spine demonstrated a dorsal epidural hematoma extending from C4 to T4, and the axial scan of the MRI revealed a posterior hematoma. Neurological deficit was estimated as not severe and not progressive, therefore surgery was postponed, and the patient was discharged without surgical intervention. Seven months later, MRI and myelography were performed, and we confirmed that the spinal epidural hematoma was absorbed. There have been some cases showing spontaneous regression of SSEH, and in younger than 18 years old, most of those cases that were treated with hematopathy such as hemophilia and spontaneous regression after SSEH correlated to larger size of hematoma. Because of bleeding tendencies in these cases the spinal cord was not pressed by the hematoma; this contributed conclusively to the prognosis. On the contrary, the 12-year-old boy, not having bleeding tendency, had the larger lesion of SSEH and recovered spontaneously without surgical intervention. Evaluation of MRI findings and neurological deficits in SSEH cases is important for deciding the indication of surgical intervention.
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22
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Lee TH, Chen CF, Lee TC, Lee HL, Lu CH. Acute thoracic epidural hematoma following spinal manipulative therapy: case report and review of the literature. Clin Neurol Neurosurg 2011; 113:575-7. [PMID: 21397387 DOI: 10.1016/j.clineuro.2011.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 11/15/2010] [Accepted: 02/05/2011] [Indexed: 01/18/2023]
Abstract
Spinal epidural hematoma is a rare complication of chiropractic manipulation. This study reports a case of thoracic spinal epidural hematoma following spinal manipulative therapy in the absence of predisposing factors. The effectiveness and safety of chiropractic treatment in chronic spinal pain and a literature review are also presented.
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Affiliation(s)
- Tsung-Han Lee
- Division of Trauma, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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23
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Spontaneous resolution of a traumatic cervicothoracic epidural hematoma presenting with transient paraplegia: a case report. Spine (Phila Pa 1976) 2010; 35:E564-7. [PMID: 20445476 DOI: 10.1097/brs.0b013e3181cd2de8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case description. OBJECTIVE To clinically and radiographically describe a traumatic spinal epidural hematoma (TSEH) without adjacent spinal column fracture or soft tissue injury that completely resolved, without surgical intervention. SUMMARY OF BACKGROUND DATA Symptomatic TSEH is an infrequent condition after spinal trauma, accounting for 0.5% to 1.7% of cases. It can result in permanent neurologic deficits if not treated in a timely and appropriate manner. METHODS A 50-year-old man presented with progressive lower motor weakness and sensory change at 2 days after blunt trauma to the upper back area. Neurologic examination revealed paraplegia and hypesthesia below the T4 sensory dermatome. Magnetic resonance imaging for cervicothoracic spine showed a space-occupying lesion in the dorsal spinal epidural space from C7 to T5. The lesion was consistent with acute stage hematoma of the spinal epidural space. RESULTS The patient was prepared for decompression surgery. However, the patient's neurologic symptoms began to improve (grade 4/5) at 2 hours after onset of paraplegia. Surgical intervention was delayed, and the patient was treated conservatively with close neurologic monitoring. Three days after onset of symptoms, the patient's neurologic symptoms recovered completely. The follow-up magnetic resonance imaging at 12 days after the event showed complete resolution of the epidural hematoma. CONCLUSION An unpredictable extensive epidural hematoma can occur after blunt trauma of the cervicothoracic spine in patients at low risk for hemorrhage. This case illustrates that immediate surgical intervention may not always be necessary in certain patients with TSEH. Conservative management with careful observation may play a role as a management option for patients initially presenting with severe neurologic dysfunction if neurologic recovery is early and sustained.
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25
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Dimou J, Jithoo R, Bush S. A patient with delayed traumatic cervical spinal epidural haematoma presenting with hemiparesis. J Clin Neurosci 2010; 17:404-5. [DOI: 10.1016/j.jocn.2009.02.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 02/22/2009] [Indexed: 01/30/2023]
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26
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Dimou J, Jithoo R, Morokoff A. Spontaneous spinal epidural haematoma in a geriatric patient on aspirin. J Clin Neurosci 2010; 17:142-4. [DOI: 10.1016/j.jocn.2009.03.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/11/2009] [Indexed: 01/28/2023]
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27
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Sarubbo S, Garofano F, Maida G, Fainardi E, Granieri E, Cavallo MA. Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1055-61. [PMID: 19859747 PMCID: PMC2899401 DOI: 10.1007/s00586-009-1175-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Indexed: 12/14/2022]
Abstract
Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.
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Affiliation(s)
- Silvio Sarubbo
- Division of Neurosurgery, Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy.
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Two children with traumatic thoracic spinal epidural hematoma. J Clin Neurosci 2009; 16:1356-8. [DOI: 10.1016/j.jocn.2009.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 01/07/2009] [Accepted: 01/08/2009] [Indexed: 01/30/2023]
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Kim IY, Kim SH, Kim JH, Lee JK. Rapid spontaneous resolution of a traumatic cervical epidural haematoma. Br J Neurosurg 2009; 19:451-2. [PMID: 16455573 DOI: 10.1080/02688690500390524] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- I Y Kim
- Department of Neurosurgery, Chonnam National University Hospital & Medical School, Gwangju, South Korea
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Delayed Onset Neurological Deterioration due to a Spinal Epidural Hematoma after a Spine Fracture. Asian Spine J 2007; 1:98-101. [PMID: 20411132 PMCID: PMC2857477 DOI: 10.4184/asj.2007.1.2.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.
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Domenicucci M, Ramieri A, Salvati M, Brogna C, Raco A. Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy. Case report and review of the literature. J Neurosurg Spine 2007; 7:571-574. [PMID: 17977203 DOI: 10.3171/spi-07/11/571] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown-Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient's preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.
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Affiliation(s)
- Maurizio Domenicucci
- Department of Neurological Sciences, Neurosurgery, University of Rome "La Sapienza", Rome, Italy.
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Whedon JM, Quebada PB, Roberts DW, Radwan TA. Spinal epidural hematoma after spinal manipulative therapy in a patient undergoing anticoagulant therapy: a case report. J Manipulative Physiol Ther 2006; 29:582-5. [PMID: 16949949 DOI: 10.1016/j.jmpt.2006.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2005] [Revised: 11/08/2005] [Accepted: 11/13/2005] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We report on the case of a patient with spinal epidural hematoma (SEH) after spinal manipulative therapy and review features of reported cases of a similar nature. CLINICAL FEATURES The patient was undergoing Coumadin anticoagulant therapy for atrial fibrillation and presented to the chiropractor complaining of a stiff neck. After cervical manipulation, he developed paresthesia in both feet, progressing to motor deficits in all 4 extremities. He required a laminectomy and evacuation of a clot indenting the spinal cord. RESULTS Review of the literature revealed 7 reported cases of SEH after manipulation; 5 patients underwent cervical manipulation and 1 patient received Coumadin therapy. CONCLUSION Practitioners of spinal manipulative therapy should be aware of SEH as a possible complication of manipulation in patients at risk and should exercise caution in the care of patients undergoing anticoagulant therapy.
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Affiliation(s)
- James M Whedon
- Trauma Program, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Horn EM, Bristol RE, Feiz-Erfan I, Beres EJ, Bambakidis NC, Theodore N. Spinal cord compression from traumatic anterior cervical pseudomeningoceles. J Neurosurg Spine 2006; 5:254-8. [PMID: 16961088 DOI: 10.3171/spi.2006.5.3.254] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
✓Pseudomeningoceles rarely develop after cervical trauma; in all reported cases the lesions have extended outside the spinal canal.
The authors report the first known cases of anterior cervical pseudomeningoceles contained entirely within the spinal canal and causing cord compression and neurological injury. The authors retrospectively reviewed the cases of three patients with traumatic cervical spine injuries and concomitant compressive anterior pseudomeningoceles. The lesion was recognized in the first case when the patient’s neurological status declined after he sustained a severe atlantoaxial injury; the pseudomeningocele was identified intraoperatively and decompressed. After the decompressive surgery, the patient’s severe tetraparesis partially resolved. In the other two patients diagnoses of similar pseudomeningoceles were established by magnetic resonance imaging. Both patients were treated conservatively, and their mild to moderate hemiparesis due to the pseudomeningocele-induced compression abated.
The high incidence of anterior cervical pseudomeningoceles seen at the authors’ institution within a relatively brief period suggests that this lesion is not rare. The authors believe that it is important to recognize the compressive nature of these lesions and their potential to cause devastating neurological injury.
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Affiliation(s)
- Eric M Horn
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Watanabe T. Traumatic spinal epidural hematoma without bone disruption. Eur J Pediatr 2006; 165:278-279. [PMID: 16320071 DOI: 10.1007/s00431-005-0038-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 10/19/2005] [Indexed: 01/30/2023]
Affiliation(s)
- Toru Watanabe
- Department of Pediatrics, Niigata City General Hospital, 2-6-1 Shichikuyama, 950-8739, Niigata, Japan.
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Fountas KN, Kapsalaki EZ, Robinson JS. Cervical epidural hematoma in children: a rare clinical entity. Neurosurg Focus 2006; 20:E6. [PMID: 16512657 DOI: 10.3171/foc.2006.20.2.7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
✓ Pediatric spinal epidural hematoma is a very rare clinicopathological entity. In the vast majority of cases, spinal epidural hematomas have a nonspecific clinical presentation; this, along with their rapid progression, makes their early diagnosis and prompt surgical evacuation critical. Magnetic resonance imaging is the neuroimaging modality of choice, whereas hemilaminectomy or laminectomy is the indicated surgical intervention. The outcome is good when hematoma evacuation is performed before the onset of complete sensorimotor paralysis.
In this communication, the authors describe a 12-year-old girl with a traumatic acute cervical epidural hematoma. This lesion was successfully evacuated through a hemilaminectomy, and the patient had an excellent outcome. The pertinent literature is reviewed in terms of the incidence, origin, management, and prognosis of this rare and potentially disastrous clinical entity.
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Affiliation(s)
- Kostas N Fountas
- Department of Neurosurgery, Medical Center of Central Georgia, School of Medicine, Mercer University, Macon, Georgia, USA.
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Abstract
Traumatic spinal epidural hematoma is rare in children. The presentation could be nonspecific, leading to a delay in diagnosis. We present an infant who sustained an epidural hematoma after a "trivial" injury. The delay in diagnosis led to minor neurological deficit at 6-week follow-up. Irritability and torticollis after a neck trauma in an afebrile child should alert to the possibility of spinal cord compression. Early imaging and early decompression will minimize morbidity.
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Affiliation(s)
- S V S Soundappan
- Department of Neurosurgery, The Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
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Chang FC, Lirng JF, Luo CB, Yen YS, Guo WY, Teng MMH, Chang CY. Evaluation of clinical and MR findings for the prognosis of spinal epidural haematomas. Clin Radiol 2005; 60:762-70. [PMID: 15978887 DOI: 10.1016/j.crad.2004.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 12/17/2004] [Accepted: 12/23/2004] [Indexed: 01/30/2023]
Abstract
AIM The potential of MR and clinical findings of spinal epidural haematomas (SEHs), particularly the early MR findings, to help minimize delays in diagnosis, to aid prognosis and as a reference for conservative treatment, are evaluated. METHODS Retrospectively 20 patients with SEHs (14 men and 6 women) were examined to record their neurological deficit, MR findings, management, clinical outcome, and interval between symptom onset and MRI or surgery. Two-tailed Fisher's exact test was used for these analyses. RESULTS Of 8 patients with severe neurological deficit at the onset of symptoms, none had obvious clinical improvement after either surgical or conservative management. Of 12 patients with mild to moderate deficits, 11 (92%) showed improvement or recovery of clinical symptoms. T2-weighted images revealed myelopathy or infarction of the compressed spinal cord in 9 patients, 7 (78%) of whom had no improvement in neurological deficit with either conservative or surgical management. Images in 6 patients showed contrast enhancement in the haematomas. CONCLUSION Poor clinical outcomes were observed mainly in those with severe neurological deficit and hyperintensity on T2-weighted images of the involved spinal cord. Surgery did not appear to improve outcome in many of these patients. In acute SEHs, MRI showed characteristic findings, such as contrast enhancement, which should not be confused with signs of inflammatory or neoplastic epidural disease.
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Affiliation(s)
- F-C Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
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Seet RCS, Wilder-Smith EPV, Ong BKC, Lim ECH. Spontaneous thoracic extradural haematoma presenting as the Brown–Sequard syndrome. J Neurol 2005; 252:731-3. [PMID: 15750709 DOI: 10.1007/s00415-005-0727-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Revised: 10/31/2004] [Accepted: 11/08/2004] [Indexed: 01/30/2023]
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Abstract
Ethical concerns have hindered any randomised control blinded studies on the imaging required to assess the cervical spine in an unconscious trauma patient. The issue has been contentious for many years and has resulted in burgeoning but inconclusive guidance. MRI and multislice CT technology have made rapid advances, but the literature is slower to catch up. Never the less there appears to be an emerging consensus for the multiply injured patient. The rapid primary clinical survey should be followed by lateral cervical spine, chest and pelvic radiographs. If a patient is unconscious then CT of the brain and at least down to C3 (and in the USA down to D1) has now become routine. The cranio-cervical scans should be a maximum of 2 mm thickness, and probably less, as undisplaced type II peg fractures, can be invisible even on 1 mm slices with reconstructions. If the lateral cervical radiograph and the CT scan are negative, then MRI is the investigation of choice to exclude instability. Patients with focal neurological signs, evidence of cord or disc injury, and patients whose surgery require pre-operative cord assessment should be imaged by MRI. It is also the investigation of choice for evaluating the complications and late sequela of trauma. If the patient is to have an MRI scan, the MR unit must be able to at least do a sagittal STIR sequence of the entire vertebral column to exclude non-contiguous injuries, which, since the advent of MRI, are now known to be relatively common. Any areas of oedema or collapse then require detailed CT evaluation. It is important that cases are handled by a suitably skilled multidisciplinary team, and avoid repeat imaging due to technical inadequacies. The aim of this review is to re-examine the role of cervical spine imaging in the context of new guidelines and technical advances in imaging techniques.
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Affiliation(s)
- Paula J Richards
- X-ray Department, University Hospital of North Staffordshire NHS Trust (UHNS), Princes Road, Hartshill, Stoke on Trent ST4 7LN, UK.
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Bennett DL, George MJ, Ohashi K, El-Khoury GY, Lucas JJ, Peterson MC. Acute traumatic spinal epidural hematoma: imaging and neurologic outcome. Emerg Radiol 2004; 11:136-44. [PMID: 16028317 DOI: 10.1007/s10140-004-0371-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The purpose of this study was to present MRI characteristics of traumatic spinal epidural hematomas (TSEHs) and to evaluate their effect on neurologic outcome. A retrospective analysis was performed of all 74 cases in which patients underwent emergent spinal MRI in the setting of acute trauma at our institution's Emergency Department between June 2002 and January 2003. MRI studies were evaluated for the presence of a TSEH. CT studies were evaluated for the presence of osseous trauma. Patient data were collected from medical records on the initial neurologic status at admission and at 6 months after injury. Twenty-seven of 74 patients had a spinal fracture and a TSEH. Twenty-five of 74 patients had a spinal fracture with no TSEH. Twenty-two of 74 patients had normal imaging studies. Six-month follow-up of neurologic status demonstrated no statistically significant difference in neurologic outcome between patients with spinal fractures and TSEH and those with spinal fractures but no TSEH. If a spinal fracture and abnormal neurologic exam are present, the neurologic outcome at 6 months is not worsened by the presence of a TSEH.
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Affiliation(s)
- D Lee Bennett
- Department of Radiology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Adamson DC, Bulsara K, Bronec PR. Spontaneous cervical epidural hematoma: case report and literature review. ACTA ACUST UNITED AC 2004; 62:156-9; discussion 159-60. [PMID: 15261513 DOI: 10.1016/j.surneu.2003.10.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2003] [Accepted: 10/06/2003] [Indexed: 12/19/2022]
Abstract
BACKGROUND Spontaneously occurring epidural hematomas for which no etiology is identified are rare phenomenon. These are often neurosurgical emergencies; therefore, prompt diagnosis and treatment are paramount. Because of the rarity of this condition, we have illustrated in this recent case its presentation, evaluation and management. METHODS A 63-year-old male presented to our emergency room with right-sided hemiparesis and contralateral hypesthesia, consistent with a C5 Brown-Séquard syndrome. An initial evaluation for cerebral infarction was unremarkable, including a negative brain magnetic resonance image. Further imaging revealed a cervical epidural hematoma of unknown etiology. RESULTS The patient underwent emergent laminectomy for decompression and evacuation of the hematoma within 24 hours of his presentation to the emergency room. The patient's symptoms improved remarkably after surgery and a 4-month follow-up imaging evaluation revealed no recurrence of his hematoma. CONCLUSION This report highlights the various presentations, evaluation, and management options for this rare diagnosis. It emphasizes the necessity of prompt diagnosis for possible emergent intervention.
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Affiliation(s)
- David C Adamson
- Division of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC 27710, USA
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Abstract
BACKGROUND CONTEXT Symptomatic epidural hematomas after spinal surgery are uncommon and are usually diagnosed within 24 hours after surgery. PURPOSE We report a series of delayed epidural hematomas in a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after their index procedure. The goals of this report are to outline the clinical presentation, radiological characteristics and outcome of this uncommon entity. STUDY DESIGN/SETTING We retrospectively reviewed the database of six spine surgeons over a 4-year period, looking for presence of epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days. PATIENT SAMPLE We identified a subset of patients who awoke from surgery neurologically unchanged and then deteriorated more than 3 days after spinal surgery. A total of 4,018 patients were identified over the 4-year period of review. OUTCOME MEASURES Presence of spinal epidural hematoma as a cause of clinical deterioration after an asymptomatic period of at least 3 days. The medical records, including the history, physical, preoperative and postoperative neurological examinations, as well as plain radiographs and magnetic resonance images, were reviewed. METHODS We retrospectively reviewed the database of six spine surgeons over a 4-year period. We looked for delayed spinal epidural hematomas as a cause of clinical deterioration after an asymptomatic postoperative period of at least 3 days. We examined potential risk factors for spinal extradural hematomas. RESULTS Of 4,018 patients, we identified seven with spinal epidural hematoma who presented more than 3 days after their index procedure. The initial presenting symptom, which heralded the subsequent onset of neurological deterioration, consisted of severe sharp pain with radiation to the extremities. The average time to neurological deterioration was 5.3 days. Fifty-seven percent of the patients had multiple previous spinal surgeries at the site of the epidural hematoma. Surgical evacuation of the epidural hematomas resulted in neurological improvement in five patients. Persistent neurological deficits were observed in two patients. CONCLUSION Delayed spinal epidural hematomas are an uncommon cause of delayed deterioration after spinal surgery. Previous surgery with attendant scarring that results in impairment of clot resorption may be a contributing factor in the development of the condition.
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Affiliation(s)
- Juan Uribe
- Department of Neurosurgery, The Miami Project to Cure Paralysis, Lois Pope Life Center, 1095 NW 14 Terrace (D-4-6), University of Miami School of Medicine, Miami, FL 33136, USA
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Bosch PP, Vogt MT, Ward WT. Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing. Spine (Phila Pa 1976) 2002; 27:2788-800. [PMID: 12486348 DOI: 10.1097/00007632-200212150-00009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken. OBJECTIVES To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA. SUMMARY OF BACKGROUND DATA There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA. METHODS All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded. RESULTS A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs. CONCLUSION We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.
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Affiliation(s)
- Patrick P Bosch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kondoh T, Kurihara E, Kohmura E. Cervical epidural hematoma after snowboarding injury--case report. Neurol Med Chir (Tokyo) 2002; 42:550-3. [PMID: 12513027 DOI: 10.2176/nmc.42.550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 21-year-old man developed cervical spinal epidural hematoma one month after a snowboarding injury. He fell down while snowboarding and hit his occiput. Immediately after the injury, he suffered hypesthesic pain in the C-8 area associated with dull neck pain, which persisted for a month. Radiography of the cervical spine detected no pathological findings. The second attack of pain occurred when he was resting, followed by paraparesis and loss of urinary sensation within 24 hours. Emergent magnetic resonance (MR) imaging demonstrated an epidural hematoma at the levels of C-7 to T-2 which compressed the spinal cord. During the operation for removal of the hematoma, arterial rebleeding occurred from a small artery in the dural sac on the right C-8 root, which was thought to be responsible for the hematoma. The patient was discharged with no neurological deficits. Snowboarding-related injuries occur with higher frequency and involve greater risks compared to skiing-related injuries. Repeat MR imaging is strongly recommended to follow up any spinal injury, particularly in cases associated with focal neurological signs.
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Affiliation(s)
- Takeshi Kondoh
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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Tseng SH, Chen Y, Lin SM, Wang CH. Cervical epidural hematoma after spinal manipulation therapy: case report. THE JOURNAL OF TRAUMA 2002; 52:585-6. [PMID: 11901345 DOI: 10.1097/00005373-200203000-00033] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Sheng-Hong Tseng
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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47
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Taguchi Y, Matsuzawa M, Ye JM, Uzura M, Watanabe H, Hayakawa M. Posttraumatic cervical epidural hematoma associated with congenital absence of a cervical spine pedicle: case report and literature review. THE JOURNAL OF TRAUMA 2001; 51:579-82. [PMID: 11535915 DOI: 10.1097/00005373-200109000-00030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Y Taguchi
- Division of Neurosurgery, Department of Radiology, St. Marianna University Yokohama City Seibu Hospital, 1197-1 Yasashi-cho, Asahi-ku, Yokohama, Kanagawa, Japan 241-0811
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Rechtine GR, Bolesta MJ, Chrin AM, Louis K. Spontaneous resolution of symptomatic post-traumatic cervical epidural hematoma. A case report. J Bone Joint Surg Am 2001; 83:255-8. [PMID: 11216688 DOI: 10.2106/00004623-200102000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Traumatic spinal epidural hematoma (TSEH) is rare in children. Only three cases of TSEH were documented in the pediatric literature. This clinical note presents an infant with TSEH but no risk factors. Without magnetic resonance imaging examination, children with TSEH and minor symptoms may be missed and under reported. Signs such as irritability and neck pain should alert the clinician to consider TSEH and the need for urgent magnetic resonance imaging of the spine for early diagnosis and treatment to minimize morbidity.
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Affiliation(s)
- N S Alva
- Department of Neurology, Brown University School of Medicine, Providence, Rhode Island 02906, USA
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La Rosa G, d'Avella D, Conti A, Cardali S, La Torre D, Cacciola F, Longo M, Tomasello F. Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases. J Neurosurg 1999; 91:128-32. [PMID: 10419360 DOI: 10.3171/spi.1999.91.1.0128] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.
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Affiliation(s)
- G La Rosa
- Department of Neurosurgery, University of Messina School of Medicine, Italy
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