Spontaneous cervical epidural hematoma

Spontaneous cervical epidural hematoma

This spontaneous spinal epidural hematoma in the cervical region is an uncommon cause of acute spinal cord compression.

Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present 1).

The cause of bleeding in the current literature is both venous and arterial in origin. Venous bleeding owing is the commonly accepted hypothesis for the source of the hematoma because spinal epidural venous plexus have no sphincters, and thus have no protection against pressure changing 2). This theory seems to be invalid in the cervical region because the venous pressure is low. It is said that the cervical epidural hematoma has an arterial source from free anastomotic arteries in connection with radicular arteries that exist in the epidural space 3).

Acute cervical epidural hematoma is definitely a condition of neurologic emergency. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurologic deficits. Patients with spontaneous spinal epidural hematoma typically present with acute onset of severe back pain, and they rapidly develop signs of compression of the spinal cord or cauda equina 4)


High index of suspicion followed by T2-weighted gradient echo sequences are particularly useful in early diagnosis. 5)

Cervical spontaneous spinal epidural hematoma is a serious neurosurgical pathology that often requires prompt surgical intervention.

Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis 6)

This is a rare idiopathic condition that leads to acute onset of neurologic deficits, which if not recognized early can have catastrophic consequences.

Hines et al. from the Thomas Jefferson University Hospital presented the first case in the literature of cervical disc extrusion provoking epidural hematoma and acute neurological deterioration.

A 65 year old male presented with six months of worsening signs and symptoms of cervical myelopathy. He had progressive deterioration over the course of two weeks leading to ambulatory dysfunction requiring a cane for assistance. While undergoing his medical workup in the emergency department, the patient became acutely plegic in the right lower extremity prompting emergent surgical decompression and stabilization.

Based on imaging, pathology, and intraoperative findings, it was concluded that the patient had an extruded disc segment that may have precipitated venous bleeding in the epidural space and findings of acute cervical spinal cord compression. Cervical disc extrusion may lead to venous damage, epidural hematoma, and spinal cord compression. If this unique presentation is recognized and addressed in a timely manner, patient outcomes may still be largely positive as this case demonstrates 7).

A 41-year-old male, diagnosed with SCEH, with a presenting chief complaint of cervical pain followed by progressive quadriparesis and urgency of micturition who was managed surgically.

SCEH is a rare pathologic entity. Due to the high risk of poor neurological outcome without treatment, SCEH should be a diagnostic possibility when the presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma and hemostasis leads to a favorable neurological outcome, whereas delay in treatment can be disastrous 8).


A 31-year-old man who presented with acute onset of neck pain with radicular component with progressive neurologic deficit. Emergent magnetic resonance imaging revealed cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery was achieved within 48 hours. The level of preoperative neurologic deficit and its severity, as well as operative interval, are important factors significantly affecting the postoperative outcome 9)


A 28-year-old healthy man developed a sudden onset of severe neck and right shoulder pain with mild arm weakness. The MRI revealed an SSEH that was compressing his spinal cord in the right posterolateral epidural space from C2-C6. On the second hospital day, his symptoms suddenly improved, and most of the hematoma had spontaneously resolved Currently, the incidence of SSEH is expected to increase. Pain physicians must include SSEH in their differential diagnosis for patients with axial pain or radicular symptoms alone, particularly when risk factors are present 10).


A 70-year-old man presented with acute onset neck pain with a radicular component and rapidly progressive quadriparesis. Magnetic resonance imaging revealed a posteriorly located cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery to near normal function occurred within 24 hours of surgery.

SSEH in its true idiopathic form is a rare pathologic entity. Because of the high risk of poor outcome without treatment, SSEH should be a diagnostic possibility when presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis 11)


A 25-year-old male presented with a history of sudden onset of complete quadriplegia with sensory loss below the neck along with loss of bowel and bladder control. He had no history of any constitutional symptoms. He reported 10 days later. He was managed conservatively and after two weeks of intensive rehabilitation he had complete neural recovery. The spontaneous recovery of neurological impairment is attributed to the spreading of the hematoma throughout the epidural space, thus decreasing the pressure with partial neural recovery. Conservative treatment is a fair option in young patients who present late and show neurological improvement. The neurological status on presentation will guide the further approach to management 12).


1) , 10)

Huh J, Kwak HY, Chung YN, Park SK, Choi YS. Acute Cervical Spontaneous Spinal Epidural Hematoma Presenting with Minimal Neurological Deficits: A Case Report. Anesth Pain Med. 2016 Aug 27;6(5):e40067. eCollection 2016 Oct. PubMed PMID: 27853682; PubMed Central PMCID: PMC5106555.
2) , 5) , 6) , 11)

Gopalkrishnan CV, Dhakoji A, Nair S. Spontaneous cervical epidural hematoma of idiopathic etiology: case report and review of literature. J Spinal Cord Med. 2012 Mar;35(2):113-7. doi: 10.1179/2045772312Y.0000000001. Epub 2012 Feb 4. PMID: 22333537; PMCID: PMC3304555.
3)

Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg. 1984 Jul;61(1):143-8. doi: 10.3171/jns.1984.61.1.0143. PMID: 6726389.
4) , 9)

Salehpour F, Mirzaei F, Kazemzadeh M, Alavi SAN. Spontaneous Epidural Hematoma of Cervical Spine. Int J Spine Surg. 2018 Mar 30;12(1):26-29. doi: 10.14444/5005. PMID: 30280079; PMCID: PMC6162037.
7)

Hines K, Hafazalla K, Bailey JW, Jallo J. Extruded disc causes acute cervical epidural hematoma and cord compression: a case report. Spinal Cord Ser Cases. 2021 May 21;7(1):39. doi: 10.1038/s41394-021-00403-8. PMID: 34021115.
8)

Taha MM, Elsharkawy AM, Al Menshawy HA, AlBakry A. Spontaneous cervical epidural hematoma: A case report and review of literature. Surg Neurol Int. 2019 Dec 13;10:247. doi: 10.25259/SNI_543_2019. PMID: 31893148; PMCID: PMC6935966.
12)

Halim TA, Nigam V, Tandon V, Chhabra HS. Spontaneous cervical epidural hematoma: report of a case managed conservatively. Indian J Orthop. 2008 Jul;42(3):357-9. doi: 10.4103/0019-5413.41863. PMID: 19753167; PMCID: PMC2739458.

Type III odontoid fracture

Type III odontoid fracture

A type III odontoid fracture is a fracture through the body of the C2 vertebrae and may involve a variable portion of the C1 and C2 facets.

Type III fractures account for 39% of all odontoid fractures 1).

Type III odontoid fractures occur secondary to hyperextension or hyperflexion of the cervical spine in a similar manner to type II odontoid fractures. The difference is where the fracture line occurs.

In clinical practice, the Type III fracture encompasses a heterogeneous collection of morphologically different fractures of varying etiologies and patient demographics. At trauma centers, a complex, high-energy subtype exists that radiographically fits the definition of Type III odontoid fracture but of unknown clinical context.

Fractures with >50% comminution of the lateral mass or secondary fracture lines extending into the vertebral body or pars interarticularis were classified as complex by Niemeier et al. Biomechanically, complex fractures exhibit the same deforming forces as all odontoid fractures with additional instability in the rotatory or coronal plane 2).

Type III odontoid fracture treatment.

In general, the Type III fracture is believed to have high healing potential due to the large fracture surface area through cancellous bone 3).

Imaging pearl. A type III odontoid fracture may be misinterpreted as odontoid fracture type II on sagittal CT because the fracture may appear to lie above the vertebral body (VB). Always check the coronal view, which more readily demonstrates the relationship of the fracture to the VB.

Acute Type III odontoid fractures were identified at a single institution from 2008 to 2015. Fractures were categorized as high- or low-energy fracture with high-energy fractures defined as those with lateral mass comminution (>50%) or secondary fracture lines into the pars interarticularis or vertebral body. Patients were treated in either a hard collar orthosis or halo vest and were followed for fracture union and stability.

One hundred and twenty-five Type III odontoid fractures were identified with 51% classified as complex fractures. Thirty-three patients met the inclusion and exclusion criteria including 15 patients treated in a halo vest and 18 in a hard collar orthosis. Mean follow-up was 32 (±44) weeks. Seven patients demonstrated progressive displacement of either 2 mm of translation or 5° of angulation and underwent delayed surgical stabilization. Two additional patients required delayed surgery for nonunion and myelopathy. Initial fracture displacement and angulation were not correlative with final outcome. No statistical advantage of halo vest versus hard collar orthosis was observed.

Complex Type III odontoid fractures are distinctly different from low-energy injuries. In the current study, 21% of patients were unsuccessfully treated nonoperatively with external immobilization and required surgery. For complex Type III fractures, they recommended initial conservative treatment, while maintaining close monitoring throughout patient recovery and fracture union 4).

A young woman who suffered a severe polytrauma secondary to a motor vehicle collision was diagnosed with a sagittal plane atlantoaxial joint dislocation associated with a type III odontoid fracture, despite adequate initial polytrauma management, the neurological damage was too critical, ultimately the decease of the patient.

The atlantoaxial joint dislocation is a rare condition of the upper cervical spine and is usually secondary to a high-energy traumatism. The disruption of the atlantoaxial ligaments originates the considered most unstable cervical spine lesion and with the highest mortality. Attributable to the kinetic the bone fracture of the Atlas and Axis are commonly related, especially the odontoid process. Early immobilization followed by surgical decompression and stabilization is primordial. Typically, these injuries have an ominous prognosis, that is aggravated if added a polytrauma affecting adjacent neurological structures and other vital organs 5).


1)

Greene KA, Dickman CA, Marciano FF, Drabier JB, Hadley MN, Sonntag VK. Acute axis fractures. Analysis of management and outcome in 340 consecutive cases. Spine (Phila Pa 1976). 1997 Aug 15;22(16):1843-52. PubMed PMID: 9280020.
2) , 4)

Niemeier TE, Dyas AR, Manoharan SR, Theiss SM. Type III odontoid fractures: A subgroup analysis of complex, high-energy fractures treated with external immobilization. J Craniovertebr Junction Spine. 2018 Jan-Mar;9(1):63-67. doi: 10.4103/jcvjs.JCVJS_152_17. PubMed PMID: 29755239; PubMed Central PMCID: PMC5934967.
3)

Hanssen AD, Cabanela ME. Fractures of the dens in adult patients. J Trauma. 1987 Aug;27(8):928-34. doi: 10.1097/00005373-198708000-00013. PMID: 3612871.
5)

Sánchez-Ortega JF, Vázquez A, Ruiz-Ginés JA, Matovelle PJ, Calatayud JB. Longitudinal atlantoaxial dislocation associated with type III odontoid fracture due to high-energy trauma. Case report and literature review. Spinal Cord Ser Cases. 2021 May 25;7(1):43. doi: 10.1038/s41394-021-00407-4. PMID: 34035212.

Neck pain after cervical laminoplasty

Neck pain after cervical laminoplasty

Axial neck pain remains the most important problem of cervical laminoplasty. Hosono et al. 1)), reviewed a series of 72 laminoplasties conducted to treat cervical spondylotic myelopathy, and found a 60% incidence of axial pain. Kawaguchi et al. 2)), reported significant axial neck pain in 44% of their patiensts. Other authors have reported incidence of axial neck pain after laminoplasty of about 30% 3)4) 5). The possible causes of axial neck pain after cervical laminoplasty are ischemia of the shoulder muscles, atrophy of nuchal muscles, and delayed union in the facet joints 6)).


Axial pain after cervical laminoplasty has been reported to be due to neck muscle disruption, especially because of detachments of muscle insertions to the C2 or C7 spinous processes, or deep extensor muscles 7) 8) 9)


A study demonstrated that C7 spinous process preserving laminoplasty decreases the incidence of aggravated axial neck pain after cervical laminoplasty 10).


The presence of anterolisthesis was associated not only with the highest odds ratio of persistent neck pain but also with significantly poorer functional outcomes. Indications for cervical laminoplasty should be carefully determined in patients with cervical anterolisthesis 11).


The use of a rigid collar after laminoplasty leads to less axial neck pain in the first 2 wk after surgery. However, there is no additional benefit with regards to range of motion, quality of life, and complication risk 12).


The preoperative CSA of the Semispinalis cervicis muscle (SC) has been reported to correlate with loss of lordosis (LL) after laminoplasty, with a CSA <154.5 mm2 associated with a 10 degrees LL.

Laminoplasty patients at the University of California San Francisco between 2009 and 2018 by 2 spine surgeons were retrospectively studied. Patients with previous cervical spine surgery or nondegenerative diagnoses were excluded. Measurements included the C2-C7 angleT1 slope, and cervical sagittal vertical axis. Preoperative DEM CSA was measured on magnetic resonance imaging. Variables associated with lordosis were analyzed with univariate analysis and multivariate logistic regression, and association between postoperative cervical alignment and the musculature was evaluated.

Seventy-six patients with a mean age of 64 years were included. The average follow-up was 22.53 months. The overall average CSA of the DEM was 2274.55 mm2 and that of the SC was 275.64 mm2. Means of both CSAs were higher in men (P<0.001). Linear regression showed no correlation between LL with CSA of the DEM or the SC (r=0.005, P=0.119; r=0.001, P=0.095). Univariate and multivariate regression showed no differences in the CSA of the DEM and SC between groups with and without LL (P=0.092, 0.117 and 0.163, 0.292). There was no correlation in LL with sex or body mass index (P>0.05).

Preoperative CSA of the deep neck extensors may not predict lordosis after cervical laminoplasty. The correlation between the preoperative SC CSA and postoperative cervical alignment may not be as strong as previously reported 13).


Axial neck pain after C3-6 laminoplasty has been reported to be significantly lesser than that after C3-7 laminoplasty because of the preservation of the C-7 spinous process and the attachment of nuchal muscles such as the trapezius and rhomboideus minor, which are connected to the scapula. The C-6 spinous process is the second longest spinous process after that of C-7, and it serves as an attachment point for these muscles. The effect of preserving the C-6 spinous process and its muscular attachment, in addition to preservation of the C-7 spinous process, on the prevention of axial neck pain is not well understood. The purpose of the current study was to clarify whether preservation of the paraspinal muscles of the C-6 spinous process reduces postoperative axial neck pain compared to that after using nonpreservation techniques.

Montano et al. studied 60 patients who underwent C3-6 double-door laminoplasty for the treatment of cervical spondylotic myelopathy or cervical ossification of the posterior longitudinal ligament; the minimum follow-up period was 1 year. Twenty-five patients underwent a C-6 paraspinal muscle preservation technique, and 35 underwent a C-6 nonpreservation technique. A visual analog scale (VAS) and VAS grading (Grades I-IV) were used to assess axial neck pain 1-3 months after surgery and at the final follow-up examination. Axial neck pain was classified as being 1 of 5 types, and its location was divided into 5 areas. The potential correlation between the C-6/C-7 spinous process length ratio and axial neck pain was examined.

The mean VAS scores (± SD) for axial neck pain were comparable between the C6-preservation group and the C6-nonpreservation group in both the early and late postoperative stages (4.1 ± 3.1 vs 4.0 ± 3.2 and 3.8 ± 2.9 vs 3.6 ± 3.0, respectively). The distribution of VAS grades was comparable in the 2 groups in both postoperative stages. Stiffness was the most prevalent complaint in both groups (64.0% and 54.5%, respectively), and the suprascapular region was the most common site in both groups (60.0% and 57.1%, respectively). The types and locations of axial neck pain were also similar between the groups. The C-6/C-7 spinous process length ratios were similar in the groups, and they did not correlate with axial neck pain. The reductions of range of motion and changes in sagittal alignment after surgery were also similar.

The C-6 paraspinal muscle preservation technique was not superior to the C6-nonpreservation technique for preventing postoperative axial neck pain 14).


1) , 6)

Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty. A noticeable complication. Spine (Phila Pa 1976). 1996 Sep 1;21(17):1969-73. doi: 10.1097/00007632-199609010-00005. PMID: 8883196.
2)

Kawaguchi Y, Kanamori M, Ishiara H, Nobukiyo M, Seki S, Kimura T. Preventive measures for axial symptoms following cervical laminoplasty. J Spinal Disord Tech. 2003 Dec;16(6):497-501. doi: 10.1097/00024720-200312000-00002. PMID: 14657744.
3)

Hidai Y, Ebara S, Kamimura M, Tateiwa Y, Itoh H, Kinoshita T, Takaoka K, Ohtsuka K. Treatment of cervical compressive myelopathy with a new dorsolateral decompressive procedure. J Neurosurg. 1999 Apr;90(2 Suppl):178-85. doi: 10.3171/spi.1999.90.2.0178. PMID: 10199246.
4)

Satomi K, Nishu Y, Kohno T, Hirabayashi K. Long-term follow-up studies of open-door expansive laminoplasty for cervical stenotic myelopathy. Spine (Phila Pa 1976). 1994 Mar 1;19(5):507-10. doi: 10.1097/00007632-199403000-00003. PMID: 8184342.
5)

Wada E, Suzuki S, Kanazawa A, Matsuoka T, Miyamoto S, Yonenobu K. Subtotal corpectomy versus laminoplasty for multilevel cervical spondylotic myelopathy: a long-term follow-up study over 10 years. Spine (Phila Pa 1976). 2001 Jul 1;26(13):1443-7; discussion 1448. doi: 10.1097/00007632-200107010-00011. PMID: 11458148.
7)

Iizuka H, Shimizu T, Tateno K, Toda N, Edakuni H, Shimada H, Takagishi K. Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image. Spine (Phila Pa 1976). 2001 Oct 15;26(20):2220-6. doi: 10.1097/00007632-200110150-00013. PMID: 11598512.
8)

Shiraishi T, Fukuda K, Yato Y, Nakamura M, Ikegami T. Results of skip laminectomy-minimum 2-year follow-up study compared with open-door laminoplasty. Spine (Phila Pa 1976). 2003 Dec 15;28(24):2667-72. doi: 10.1097/01.BRS.0000103340.78418.B2. PMID: 14673367.
9)

Takeshita K, Seichi A, Akune T, Kawamura N, Kawaguchi H, Nakamura K. Can laminoplasty maintain the cervical alignment even when the C2 lamina is contained? Spine (Phila Pa 1976). 2005 Jun 1;30(11):1294-8. doi: 10.1097/01.brs.0000163881.32008.13. PMID: 15928555.
10)

Cho CB, Chough CK, Oh JY, Park HK, Lee KJ, Rha HK. Axial neck pain after cervical laminoplasty. J Korean Neurosurg Soc. 2010 Feb;47(2):107-11. doi: 10.3340/jkns.2010.47.2.107. Epub 2010 Feb 28. PMID: 20224708; PMCID: PMC2836444.
11)

Kimura A, Shiraishi Y, Inoue H, Endo T, Takeshita K. Predictors of Persistent Axial Neck Pain After Cervical Laminoplasty. Spine (Phila Pa 1976). 2018 Jan 1;43(1):10-15. doi: 10.1097/BRS.0000000000002267. PMID: 28591073.
12)

Cheung JPY, Cheung PWH, Law K, Borse V, Lau YM, Mak LF, Cheng A, Samartzis D, Cheung KMC. Postoperative Rigid Cervical Collar Leads to Less Axial Neck Pain in the Early Stage After Open-Door Laminoplasty-A Single-Blinded Randomized Controlled Trial. Neurosurgery. 2019 Sep 1;85(3):325-334. doi: 10.1093/neuros/nyy359. PMID: 30113664.
13)

Liu J, Xie R, Ruan H, Rivera J, Li B, Mahmood B, Lee J, Guizar R 3rd, Mahmoudieh Y, Mummaneni PV, Chou D. The Preoperative Cross-sectional Area of the Deep Cervical Extensor Muscles Does Not Predict Loss of Lordosis After Cervical Laminoplasty. Clin Spine Surg. 2021 May 24. doi: 10.1097/BSD.0000000000001199. Epub ahead of print. PMID: 34029263.
14)

Mori E, Ueta T, Maeda T, Yugué I, Kawano O, Shiba K. Effect of preservation of the C-6 spinous process and its paraspinal muscular attachment on the prevention of postoperative axial neck pain in C3-6 laminoplasty. J Neurosurg Spine. 2015 Mar;22(3):221-9. doi: 10.3171/2014.11.SPINE131153. Epub 2014 Dec 19. PubMed PMID: 25525962.
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