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.

Spinal epidural abscess

Spinal epidural abscess

Spinal infection in the epidural space.

Epidemiology

Spinal epidural abscess epidemiology.

Classification

It is possible to distinguish two types of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males 1).

see Cervical spinal epidural abscess.

see Lumbar spinal epidural abscess.

Etiology

Spinal epidural abscess etiology.

Pathophysiology

Spinal epidural abscess pathophysiology.

Clinical features

Spinal epidural abscess clinical features.

Diagnosis

Spinal epidural abscess diagnosis.

Differential diagnosis

Spinal epidural abscess differential diagnosis.

Treatment

Spinal epidural abscess treatment.

Outcome

Spinal epidural abscess outcome.

Case series

Spinal epidural abscess case series.

Case reports

Spinal epidural abscess case reports.

1)

Maiese A, Volonnino G, Viola RV, Nelson Cavallari E, Fazio V, Arcangeli M, La Russa R. A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention. Clin Ter. 2020 Jan-Feb;170(1):e15-e18. doi: 10.7417/CT.2020.2183. PubMed PMID: 31850479.

Epidural Steroid Injection

Epidural Steroid Injection

Indications

Epidural steroid injections (ESIs) are a common method for back pain management and treating inflammation associated with low back related leg pain, or neck related arm pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine.

History

They have been used in the treatment of lumbar radicular pain syndromes since 1952. These injections have been performed blind, using an interlaminar loss of resistance technique with a 13-30% incidence of improper localization of the space

X-ray confirmation of site is essential for difficult extradural blocks, or when neurolytic solutions are introduced into the spinal canal 1).

Types

Complications

Case series

One hundred forty-one patients met the inclusion/exclusion criteria; 89 received Epidural Steroid Injection (ESI) and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility were driven by overall costs as opposed to QALY gains. Medical management alone was more cost-effective at both points owing to lower expenditures, however, these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient-reported outcomes at the 6-month time point.

ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provides significant improvements in QOL outcomes 2).

References

1)

Mehta M, Salmon N. Extradural block. Confirmation of the injection site by X-ray monitoring. Anaesthesia. 1985 Oct;40(10):1009-12. PubMed PMID: 4061788.
2)

Pennington Z, Swanson MA, Lubelski D, Mehta V, Alvin MD, Fuhrman H, Benzel EC, Mroz TE. Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy. Clin Neurol Neurosurg. 2020 Jan 13;191:105675. doi: 10.1016/j.clineuro.2020.105675. [Epub ahead of print] PubMed PMID: 31954364.
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