Spinal cord injuryepidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. With decompressive surgery and proactive interventions to improve spinal cord perfusion, early treatment has become more intensive. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries.
Traumatic spinal cord injuries (TSCIs) affect up to 500,000 people worldwide each year, and their high morbidity is associated with substantial individual and societal burden and socioeconomic impact 1)2).
TSCIs most commonly affect young males and result from road traffic accidents, but recent reports also highlight their increasing incidence in older adults as a result of low-energy falls 3)4)5).
Kelly-Hedrick et al. reviewed four registry networks, The NACTN Spinal Cord Injury Registry, The Spinal Cord Injury Model Systems (SCIMS) Database, The Rick Hansen Spinal Cord Injury Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury Study (EMSCI). They compared the registries’ focuses, data platforms, advanced analytics use, and impacts. They also describe how registries’ data can be combined with EHR or shared using federated analysis to protect registrants’ identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes like early decompression. They’ve also revealed latent disease-modifying factors, helped develop clinical trial stratification models and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science 6).
Singh A., Tetreault L., Kalsi-Ryan S., Nouri A., Fehlings M.G. (2014). Global prevalence and incidence of traumatic spinal cord injury. Clin. Epidemiol. 6, 309–331
Noonan V.K., Fingas M., Farry A., Baxter D., Singh A., Fehlings M.G., Dvorak M.F. (2012). Incidence and prevalence of spinal cord injury in Canada: a national perspective. Neuroepidemiology 38, 219–226
Selvarajah S., Hammond E.R., Haider A.H., Abularrage C.J., Becker D., Dhiman N., Hyder O., Gupta D., Black J.H., 3rd, Schneider E.B. (2014). The burden of acute traumatic spinal cord injury among adults in the United States: an update. J. Neurotrauma 31, 228–238
Wyndaele M., Wyndaele J.J. (2006). Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord 44, 523–529
Kelly-Hedrick M, Abd-El-Barr M, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan VK, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest J. The Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma. 2022 Dec 28. doi: 10.1089/neu.2022.0450. Epub ahead of print. PMID: 36576020.
Lumbar decompression surgery for spinal canal stenosis outcome
Lumbar laminectomy, represents the standard operative treatment for lumbar spinal stenosis, but this procedure is often combined with fusion surgery. It is still discussed whether minimal-invasive decompression procedures are sufficient and if they compromise spinal stability as well.
Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain 1).
Currently, there is interest in minimally invasive surgery and various technical modifications of decompressive lumbar laminectomy without fusion.
Particularly, depression has been shown to be associated with less improvement following lumbar fusion surgery 2)3)4)5)6)7)8).
Karp et al. 9) reviewed 158 patients who underwent epidural spinal injections for low-back pain with or without radiculopathy. These investigators found that depression and sleep disturbance were prognostic of worse Patient-Reported Outcome Measurement Information System (PROMIS) outcomes following epidural spinal injections.
Hägg et al. 10) performed a randomized controlled trial of 264 patients with severe chronic low-back pain who underwent either surgical or nonsurgical treatment, and assessed the impact of underlying affective disorders. They found that baseline depression correlated with worse outcomes following both operative and nonoperative treatment.
Interestingly, they also observed that depressed patients tended to have better outcomes with nonoperativecare, whereas nondepressed patients tended to have better outcomes with fusion.
In the study of Lubelski et al. 11) found that worsening depression (as measured by the PHQ-9) independently significantly predicted worse EQ-5D index outcomes following conservative treatment for LSS (p = 0.0002). This effect was most evident when comparing patients with severe depression, who improve 0.14 points less than those with no depression. This difference exceeds the MCID and confirms that depression is a poor prognostic factor for QOL improvement following nonoperative treatment for LSS. Further investigation is needed to determine whether treatment of depression prior to conservative or surgical management of LSS will improve posttreatment QOL outcomes. There are several limitations that should be considered when interpreting the results. Multiple treating physicians were included, and factors such as participation in physical therapy, treatment with NSAIDs, opioid medications and other nonsurgical treatments varied by practitioner and patient; this increases the variability, but also improves the generalizability.
They adjusted for the increased variability by using the random effect in the regression models. Many patients were also lost to follow-up at the 4-month evaluation.
The cohorts were similar for most characteristics; however, there were statistically significant, albeit small differences for estimated percent below poverty threshold and median income by zip code. The analysis is only valid for patients who did follow-up assessments at these time points. Additionally, this was a retrospective study with a relatively short follow-up period.
Prospectively designed studies with longer follow-up are needed to further validate the findings. Nonetheless, this is the largest study investigating the correlation between depression and QOL outcomes following conservative management of LSS.
Lubelski et al. have used the validated PHQ-9 measure of depression and have found a statistically and clinically significant impact on EQ-5D index outcomes.
The results of this study suggest that depressed patients with LSS have significantly less improvement following conservative management compared with nondepressed patients. Both physicians and surgeons who treat patients with LSS should consider using validated questionnaires such as the PHQ-9 for pretreatment evaluation of depression, to better assess the likelihood of success following treatment. Further investigation is needed to evaluate the effect of depression treatment prior to management of the spinal disorder. Future prospective studies with longer follow-up intervals may be useful in further evaluating the QOL outcomes in this patient population 12).
In cases of lumbar spinal stenosis (LSS) treated with surgical decompression, a postoperative magnetic resonance imaging (MRI) is sometimes required. In the experience of a study, the obtained decompression observed on early postoperative MRI tends to be disappointing compared to the decompression achieved intraoperatively. This raises the question of whether the early postoperative MRI, performed after lumbar decompression, is a fair representation of the ‘real’ decompression. A study investigated the correlation between intraoperative and postoperative measurements of the lumbar spinal canal.
Surgical decompression of the spinal canal effectively decreases the compression of the dural sac. However, early postoperative MRI after lumbar decompression does not adequately represent the decompression achieved intraoperatively 13).
Back pain improvement
Through the 1st postoperative year, patients with lumbar stenosis-without spondylolisthesis, scoliosis, or sagittal malalignment-and clinically significant back pain improved after decompression-only surgery 14).
The most common surgical method currently used is lumbar laminectomy, with complete decompression; this technique has a 5-year follow-up effective rate of 81.6% 15).
Complications
Apart from acute complications such as hematoma and infections, same-level recurrent lumbar stenosis and adjacent-segment disease (ASD) are factors that can occur after index lumbar spine surgery.
While looking for predictors of revision surgery due to re-stenosis, instability or same/adjacent segment disease none of these were found. Within our cohort no significant differences concerning demographic, peri-operative and radiographic data of patients with or without revision wer noted. Patients, who needed revision surgery were older but slightly healthier while more likely to be male and smoking. Surprisingly, significant differences were noted regarding the distribution of intraoperative and early postoperative complications among the 6 main surgeons while these weren’t obious within the intial index group of late revisions 16).
Review of 11 studies reveals that the majority of elderly patients exhibit significant symptomatic improvement, with overall benefits observed for pain (change visual analog scale4.4 points) and disability (change Oswestry Disability Index 23 points). Review of 11 studies reveals that perioperative complications were infrequent and acceptable with pooled estimates of mortality (0.5%), inadvertent durotomy (5%), and wound infection (2%). Outcomes seem less favorable with greater complication rates among patients with diabetesor obesity.
Based on largely low-quality, retrospective evidence, Shamji et al. recommend that elderly patients should not be excluded from surgical intervention for symptomatic lumbar spinal stenosis 17).
Revision surgery
Fusion Is Not a Safeguard to Prevent Revision Surgery in Lumbar Spinal Stenosis 18).
A cohort study showed no significant association between the type of index operation for Degenerative Lumbar Spinal Stenosis-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life 19).
Geiger MF, Bongartz N, Blume C, Clusmann H, Müller CA. Improvement of Back and Leg Pain after Lumbar Spinal Decompression without Fusion. J Neurol Surg A Cent Eur Neurosurg. 2018 Dec 5. doi: 10.1055/s-0038-1669473. [Epub ahead of print] PubMed PMID: 30517963.
Aalto TJ, Malmivaara A, Kovacs F, Herno A, Alen M, Salmi L, et al: Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 31:E648–E663, 2006
Adogwa O, Parker SL, Shau DN, Mendenhall SK, Bydon A, Cheng JS, et al: Preoperative Zung depression scale predicts patient satisfaction independent of the extent of improvement after revision lumbar surgery. Spine J 13:501–506, 2013
Chaichana KL, Mukherjee D, Adogwa O, Cheng JS, McGirt MJ: Correlation of preoperative depression and somatic perception scales with postoperative disability and quality of life after lumbar discectomy. J Neurosurg Spine 14:261– 267, 2011
Sinikallio S, Aalto T, Airaksinen O, Herno A, Kröger H, Viinamäki H: Depressive burden in the preoperative and early recovery phase predicts poorer surgery outcome among lumbar spinal stenosis patients: a one-year prospective follow-up study. Spine (Phila Pa 1976) 34:2573–2578, 2009
Karp JF, Yu L, Friedly J, Amtmann D, Pilkonis PA: Negative affect and sleep disturbance may be associated with response to epidural steroid injections for spine-related pain. Arch Phys Med Rehabil 95:309–315, 2014
Hägg O, Fritzell P, Ekselius L, Nordwall A: Predictors of outcome in fusion surgery for chronic low back pain. A report from the Swedish Lumbar Spine Study. Eur Spine J 12:22–33, 2003
Lubelski D, Thompson NR, Bansal S, Mroz TE, Mazanec DJ, Benzel EC, Khalaf T. Depression as a predictor of worse quality of life outcomes following nonoperative treatment for lumbar stenosis. J Neurosurg Spine. 2015 Mar;22(3):267-72. doi: 10.3171/2014.10.SPINE14220. Epub 2014 Dec 19. PubMed PMID: 25525957.
Schenck C, van Susante J, van Gorp M, Belder R, Vleggeert-Lankamp C. Lumbar spinal canal dimensions measured intraoperatively after decompression are not properly rendered on early postoperative MRI. Acta Neurochir (Wien). 2016 May;158(5):981-8. doi: 10.1007/s00701-016-2777-5. Epub 2016 Mar 23. PubMed PMID: 27005673; PubMed Central PMCID: PMC4826663.
Crawford CH 3rd, Glassman SD, Mummaneni PV, Knightly JJ, Asher AL. Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain. J Neurosurg Spine. 2016 Nov;25(5):596-601. PubMed PMID: 27285666.
Bouras T, Stranjalis G, Loufardaki M, Sourtzis I, Stavrinou LC, Sakas DE. Predictors of long-term outcome in an elderly group after laminectomy for lumbar stenosis. J Neurosurg Spine. 2010;59:329–34.
Melcher C, Paulus AC, Roßbach BP, Gülecyüz MF, Birkenmaier C, Schulze-Pellengahr CV, Teske W, Wegener B. Lumbar spinal stenosis – surgical outcome and the odds of revision-surgery: Is it all due to the surgeon? Technol Health Care. 2022 Jun 10. doi: 10.3233/THC-223389. Epub ahead of print. PMID: 35754243.
Austevoll IM, Ebbs E. Fusion Is Not a Safeguard to Prevent Revision Surgery in Lumbar Spinal Stenosis. JAMA Netw Open. 2022 Jul 1;5(7):e2223812. doi: 10.1001/jamanetworkopen.2022.23812. PMID: 35881401.
Ulrich NH, Burgstaller JM, Valeri F, Pichierri G, Betz M, Fekete TF, Wertli MM, Porchet F, Steurer J, Farshad M; Lumbar Stenosis Outcome Study Group. Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis. JAMA Netw Open. 2022 Jul 1;5(7):e2223803. doi: 10.1001/jamanetworkopen.2022.23803. PMID: 35881393.
Any residual motor or sensory function is more than 3 segments below the level of the injury.
Look for signs of preserved long-tract function.
Signs of incomplete lesion:
sensation (including position sense) or voluntary movement in the LEs in the presence of a cervical or thoracic spinal cord injury
“sacral sparing”: preserved sensation around the anus, voluntary rectal sphincter contraction, or voluntary toe flexion
an injury does not qualify as incomplete with preserved sacral reflexes alone (e.g. bulbocavernosus)
An incomplete spinal cord injury is the term used to describe damage to the spinal cord that is not absolute. The incomplete injury will vary enormously from person to person and will be entirely dependant on the way the spinal cord has been compromised.
An “incomplete” spinal cord injury involves preservation of motor or sensory function below the level of injury in the spinal cord.
If the patient has the ability to contract the anal sphincter voluntarily or to feel a pinprick or touch around the anus, the injury is considered to be incomplete. The nerves in this area are connected to the very lowest region of the spine, the sacral region, and retaining sensation and function in these parts of the body indicates that the spinal cord is only partially damaged. This includes a phenomenon known as sacral sparing.
The true extent of many incomplete injuries isn’t fully known until 6-8 weeks post injury. The spinal cord normally goes into what is called spinal shock after it has been damaged. The swelling and fluid masses showing on any resultant X-ray, MRI or CT scans, may well mask the true nature of the underlying injury. It is not uncommon for someone who is completely paralysed at the time of injury to get a partial or very near full recovery from their injuries after spinal shock has subsided.
The results of kinesiotherapy treatment in patients after incomplete spinal cord injury (iSCI) are inconclusive, mostly due to different, subjective evaluation methods. A study aimed to evaluate the range of functional regeneration in long-term 13 months follow-up using comparative neurophysiological tests after uniform kinesiotherapy in patients with thoracic iSCI.
Material and methods: Comparative tests were performed of sensory perception in dermatomes Th1-S1, electromyography (at rest-rEMG and during maximal contraction-mcEMG) in the muscles of the trunk and lower extremities, electroneurography (ENG) of the motor fibers of the lower extremities, and motor-evoked potential induced transcranially (MEP) before and after treatment in 25 iSCI patients. All subjects were treated with the same kinesiotherapeutic procedures.
A moderate increase was found in amplitudes in rEMG and mcEMG recordings from the rectus abdominis and rectus femoris muscles, MEPs amplitudes, and amplitudes after peroneal nerve stimulations in ENG studies. There was no improvement in sensory perception.
Following the proposed kinesiotherapy algorithm, patients after thoracic iSCI presented a moderate more motor than sensory functions improvement. Applied neurorehabilitation evoked normalization of muscle tension, moderate improvement of rectus abdominis and rectus femoris muscles motor units activity, and motor central and peripheral neural impulses transmission. The comparative neurophysiological assessment provides more precise and objective insight into the functional status of afferent and efferent systems than the classical clinical approach in iSCI patients 1).
Outcome
Following incomplete spinal cord injuries, neonatal mammals display a remarkable degree of behavioral recovery.
Previously, it has been demonstrated in neonatal mice a wholesale re-establishment and reorganization of synaptic connections from some descending axon tracts (Boulland et al., 2013).
To assess the potential cellular mechanisms contributing to this recovery, Chawla et al., have characterized a variety of cellular sequelae following thoracic compression injuries, focusing particularly on cell loss and proliferation, inflammation and reactive gliosis, and the dynamics of specific types of synaptic terminals. Early during the period of recovery, regressive events dominated. Tissue loss near the injury was severe, with about 80% loss of neurons and a similar loss of axons that later make up the white matter. There was no sign of neurogenesis, no substantial astroglial or microglial proliferation, no change in the ratio of M1 and M2 microglia and no appreciable generation of the terminal complement peptide C5a. One day after injury the number of synaptic terminals on lumbar motoneurons had dropped by a factor of 2, but normalized by 6 days. The ratio of VGLUT1/2+ to VGAT+ terminals remained similar in injured and uninjured spinal cords during this period. By 24 days after injury, when functional recovery is nearly complete, the density of 5HT+ fibers below the injury site had increased by a factor of 2.5. Altogether this study shows that cellular reactions are diverse and dynamic. Pronounced recovery of both excitatory and inhibitory terminals and an increase in serotonergic innervation below the injury, coupled with a general lack of inflammation and reactive gliosis, are likely to contribute to the recovery 2).
Wincek A, Huber J, Leszczyńska K, Fortuna W, Okurowski S, Tabakow P. Results of a long-term uniform system of neurorehabilitation in patients with incomplete thoracic spinal cord injury. Ann Agric Environ Med. 2022 Mar 21;29(1):94-102. doi: 10.26444/aaem/135554. Epub 2021 Apr 15. PMID: 35352911.
Chawla RS, Züchner M, Mastrangelopoulou M, Lambert FM, Glover JC, Boulland JL. Cellular reactions and compensatory tissue re-organization during spontaneous recovery after spinal cord injury in neonatal mice. Dev Neurobiol. 2016 Dec 29. doi: 10.1002/dneu.22479. [Epub ahead of print] PubMed PMID: 28033684.
Radiofrequency ablation for Spinal osteoid osteoma
Complete excision With osteoid osteomas, only complete surgical excision ensures the least risk of local recurrence, and effectively provides immediate pain relief and early mobilization. Newer, minimally invasive methods, including. percutaneous CT-guided radiofrequency ablation (RFA), are gaining popularity internationally for the treatment of extra spinal tumors 1).
Complete surgical excision of the nidus is curative, providing symptomatic relief, and is the traditionally preferred treatment. However, surgery has disadvantages, including the difficulty of locating the lesion intraoperatively, the need for prolonged hospitalization, and the possibility of postoperative complications ranging from an unsatisfactory cosmetic result to a fracture. Percutaneous radiofrequency (RF) ablation, which involves the use of thermal coagulation to induce necrosis in the lesion, is a minimally invasive alternative to surgical treatment of osteoid osteoma. With reported success rates approaching 90%, RF ablation should be considered among the primary options available for treating this condition 2).
PubMed, Scopus, and CENTRALdatabases were searched in accordance with PRISMA guidelines. Studies with available data on safety and clinical outcomes following RFA for spinal OO were included.
In the 14 included studies (11 retrospective; 3 prospective), 354 patients underwent RFA for spinal OO. The mean ages ranged from 16.4 to 28 years (Females = 31.3%). Lesion diameters ranged between 3 and 20 mm and were frequently seen in the posterior elements in 211/331 (64%) patients. The mean distance between OO lesions and neural elements ranged between 1.7 and 7.4 mm. The estimated pain reduction on the numerical rating scale was 6.85/10 (95% confidence intervals [95%CI] 4.67-9.04) at a 12-24-month follow-up; and 7.29/10 (95% CI 6.67-7.91) at a >24-month follow-up (range 24-55 months). Protective measures (e.g., epidural air insufflation or neuroprotective sterile water infusion) were used in 43/354 (12.1%) patients. Local tumor progression was seen in 23/354 (6.5%) patients who were then successfully re-treated with RFA or open surgical resection. Grade I-II complications such as temporary limb paresthesia and wound dehiscence were reported in 4/354 (1.1%) patients. No Grade III-V complications were reported.
RFA demonstrated safety and clinical efficacy in most patients harboring painful spinal OO lesions. However, further prospective studies evaluating these outcomes are warranted 3).
Case series
Percutaneous Radiofrequency Ablation Using a Navigational Bipolar Electrode System 4).
Between 2002 and 2012, a total of 61 patients (46 male and 15 female, mean age 26.4 ± 12.7 years) were subjected to RFA for spinal OO. The diagnosis of OO was made after a period of pain and symptoms of 20.6 ± 14.4 months. RFA was performed under conscious sedation and local analgesia. Clinical symptoms were evaluated at 3, 6, and12 months, and at the end of the time of the present investigation. Mean follow-up was 41.5 ± 7.1 months.
Results: The primary efficacy of RFA, complete regression of symptoms, was obtained in 57 out of 61 patients (93.4%). Four out of 61 (6.5%) patients showed a relapse of OO (after 3 months); 2 out of 4 were subjected to a second RFA, the remaining ones were subjected to surgery. There was one complication (case of lower limb paresthesia for 30 days after the ablation) and one possible complication (a disc herniation).
Conclusion: CT-guided RFA is an excellent treatment for spinal OO. Our data suggest that this procedure should be considered for the first stage of therapy for this disease 5)
Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity 6).
The records of all patients with osteoid osteomas of the spine managed with thermal ablation at two academic centers from 1993 to 2008 were reviewed.
Results: Seventeen patients (13 male patients, four female patients; mean age, 25.9 years) had lesions in the lumbar (seven patients), thoracic (six patients), cervical (three patients), and sacral (one patient) regions of the spine. Two lesions were in the vertebral body, one was within the dens, and the others were in the posterior elements. The mean lesion diameter was 8.8 mm, and the mean distance between the lesion and the closest neural element was 4.3 mm. The lesions were managed with laser (13 lesions) or radiofrequency (four lesions) ablation. Special thermal protection techniques involving the epidural injection of gas or cooled fluid were used. Pain levels were assessed immediately before the procedure and on the day after the procedure. Long-term follow-up findings were available for 11 patients. No complications were encountered, and all patients reported relief of pain. The 11 patients who participated in long-term follow-up reported continued relief of pain.
Conclusion: Percutaneous thermal ablation can be used to manage spinal osteoid osteomas close to the neural elements. Special thermal protection techniques may add a margin of safety 7).
A prospective study on 24 patients with spinal osteoid osteoma treated with radiofrequency ablation (RFA).
Objective: To determine if and when computed tomography (CT)-guided RFA is a safe and effective treatment for spinal osteoid osteomas.
Summary of background data: Surgery has been considered the standard treatment for spinal osteoid osteomas. Surgery may cause spinal instability, infection, and nervous injury. We evaluated CT-guided RFA as an alternative treatment.
Methods: A total of 28 RFA procedures in 24 patients with spinal osteoid osteoma were performed, using a 5-mm noncooled electrode. Clinical symptoms and spinal deformity were evaluated before and after the procedure. Unsuccessful treatment was defined as the presence of residual or recurrent symptoms. The mean follow-up was 72 months (range: 9-142 months).
Results: Nineteen (79%) patients were successfully treated after 1 RFA, and all except one after repeat RFA. One patient with nerve root compression needed further surgery. No complications were observed. Spinal deformity persisted in 3 of 7 patients after successful RFA.
Conclusion: CT-guided RFA is a safe and effective treatment for spinal osteoid osteoma. Surgery should be reserved for lesions causing nerve root compression 8).
Gasbarrini A, Cappuccio M, Bandiera S, Amendola L, van Urk P, Boriani S. Osteoid osteoma of the mobile spine: surgical outcomes in 81 patients. Spine (Phila Pa 1976). 2011 Nov 15;36(24):2089-93. doi: 10.1097/BRS.0b013e3181ffeb5e. PMID: 21304430.
Rybak LD, Gangi A, Buy X, La Rocca Vieira R, Wittig J. Thermal ablation of spinal osteoid osteomas close to neural elements: technical considerations. AJR Am J Roentgenol. 2010 Oct;195(4):W293-8. doi: 10.2214/AJR.10.4192. PMID: 20858792.
They are benign tumors composed of mature lipocytes admixed with abnormal blood vessels.
Only 129 cases of spinal epidural angiolipomas have been reported in literature till 2012. 171 cases till 2017 1)
Spinal angiolipomas are predominantly located in the mid-thoracic region 2).
Clinical features
The angiolipomas of the spine are rare causes of spinal cord compression that generally induce slow progressive cord compression, but sudden onset or rapid worsening of neurological deterioration is observed in hemorrhagic spinal angiolipoma 3).
Differential diagnosis
Multiple MRI technology for characterization of SAL provides useful information for differential diagnosis and therapeutic management 4).
Liu et al. published a spinal epidural angiolipoma with a special pattern of calcification misdiagnosed as meningioma 5)
Case series
Three cases of epidual spinal angiolipoma from ethnic Han Chinese patients were presented, including one lumbar and two thoracic tumors. MRI imaging findings were reviewed.
Multiple MRI technology for characterization of SAL provides useful information for differential diagnosis and therapeutic management 6).
Case reports
Spinal epidural angiolipoma with a special pattern of calcification misdiagnosed as meningioma 7)
A 49-year-old female with obesity presented with a 1-week history of progressively worsening back pain, paresthesia of lower limbs, and gait disturbance. When thoracic magnetic resonance imaging (MRI) revealed a dorsal epidural mass at the Th5-Th8 level, the patient underwent a laminectomy for gross total excision of the lesion. Both mature fatty tissue and abnormal proliferating vascular elements with thin or expanded walls were observed in the resected tumor. Nonfiltrating spinal angiolipoma was diagnosed and confirmed by pathology. After the operation, sensory loss, numbness, and gait disturbance were improved following the disappearing severe back pain. Following examinations indicated the absence of recurrence within 1 year. The angiolipomas of the spine are rare causes of spinal cord compression that generally induce slow progressive cord compression, but sudden onset or rapid worsening of neurological deterioration is observed in hemorrhagic spinal angiolipoma 8).
Rkhami et al. report the case of a 65 years-old-woman, presenting with complete paraplegia installed since 7 months. Magnetic resonance imaging (MRI) showed an epidural dorsal fatty mass. The patient recovered immediately after surgery. The pathological examination concluded to an angiolipoma.
Angiolipoma patients most commonly have long-lasting pain and then develop progressive neurological symptoms secondary to spinal cord compression. The mean duration of symptom progression at diagnosis is 1 year. MRI is the most reliable examination for the diagnosis of spinal angiolipoma. Total resection is the treatment of choice. No adjuvant treatment is indicated. Since SAL are very haemorrhagic lesions, preoperative embolization is recommended.
A 56-year-old male who presented with paraparesis and was diagnosed to have D4-5 epidural angiolipoma. Total surgical excision of the epidural angiolipoma was done and his paraparesis gradually improved 10).
Leu et al. presented the MR imaging findings of a pathologically proved infiltrating spinal epidural angiolipoma that appeared largely hypointense on T1-weighted images and enhanced strongly with IV injection of contrast medium, features that suggested a malignant tumor 11).
Wang FF, Wang S, Xue WH, Cheng JL. Epidural spinal angiolipoma: a case series. BMC Res Notes. 2017 Mar 20;10(1):128. doi: 10.1186/s13104-017-2432-0. PMID: 28320469; PMCID: PMC5359808.
Liu J, Lin Y, Li J, Fan J, Yang X. Spinal epidural angiolipoma with a special pattern of calcification misdiagnosed as meningioma. Acta Neurol Belg. 2022 Feb 7. doi: 10.1007/s13760-022-01881-9. Epub ahead of print. PMID: 35129795.
Rkhami M, Kedous MA, Achoura S, Zehani A, Bahri K, Zammel I. Epidural angiolipoma: A rare cause of spinal cord compression. Int J Surg Case Rep. 2018 Mar 15;45:72-76. doi: 10.1016/j.ijscr.2018.03.005. [Epub ahead of print] PubMed PMID: 29573600.
There are a few case reports of intradural arachnoid cysts associated with syringomyelia, but recent evidence suggests that its occurrence is more common than previously thought. A combination of these two diseases is thought to be caused by blockage of cerebrospinal fluid (CSF) flow, which is also thought to cause adhesive arachnoiditis. For this reason, resection of the arachnoid cyst could improve the CSF flow and contribute to the shrinkage of syringomyelia 2).
Especially, idiopathic lesions, in which other possible etiological factors have been ruled out, seem to be rare.
It may be reasonable to include serum ELISA in the differential diagnosis of spinal intradural cystic lesions, particularly in cysticercosis endemic regions such as Korea 4).
The detection of an intradural cystic lesion through MRI leads primarily to a differential diagnosis of arachnoid cyst versus spinal cysticercosis, based on incidence. Moreover, other lesions, such as dermoid cysts, hydatid cysts, tuberculosis, sarcoidosis, and forms of subarachnoid neoplasia, have to be taken into consideration in the differential diagnosis of the disease 5).
MRI is a sensitive diagnostic tool for the identification of cystic lesions in the spine; however, it is difficult to distinguish cysticercosis from a noninfectious cyst, such as an arachnoid cyst, without using gadolinium enhancement. Contrast-enhanced MRI is mandatory for evaluating spinal cysticercosis 6)
The wall of the arachnoid cyst does not appear enhanced, whereas that of the cysticerci are well enhanced in gadolinium enhanced MR images 7).
The cyst walls were enhanced in all reported PSC cases. Moreover, the MRI sequence can distinguish between the CSF like fluid of the arachnoid cyst and the protein-rich fluid of an infectious cyst 8).
Because arachnoid cysts have a low concentration of metabolites, similar to the CSF, the signal intensity is not increased relative to that of the CSF. On T2-weighted MR images, the signal intensity of neurocysticercosis is increased because of its higher protein content.
The experience with a case and the review of the published literature suggest that contrast-enhanced MRI may provide useful information in the differential diagnosis of spinal cystic lesions, especially in patients with an unusual clinical course 9).
Although MRI is the method of choice for the diagnosis of neurocysticercosis, particularly in the presence of calcification, computed tomography (CT) has an advantage compared with MRI 10).
The initial stage of cysticercosis is characterized by less tissue response. At this stage, CT shows areas of decreased density surrounding the lesion and does not have an advantage compared with MRI as a diagnostic method. At the final stage of the disease, the dead larvae have calcified, and CT shows multiple calcified nodules, which are best identified on CT compared with MRI 11).
Treatment
Early treatment may correlate with improvement in radiological findings and neurological symptoms.
Case report
2015
A 69-year-old man with a spinal arachnoid cyst of the thoracic spine presented with gait disturbance. Magnetic resonance images showed a mild anterior displacement and flattening of the spinal cord at T4-T5. They performed ultrasonography before incision of the dura during the operation and observed the movement of the cyst consisting of not only pulsation in accordance with the cardiac cycle but also rhythmic expansion and contraction in accordance with the respiratory cycle. In the inspiratory phase, the cyst gradually expanded and pulsated in accordance with the cardiac cycle. In the expiratory phase, the cyst gradually contracted with the same pulsation. After resection of the cyst, the patient’s neurological improvements were excellent. This is the first report of animated respiratory movement of a spinal arachnoid cyst visualized by intraoperative ultrasonography. Although cine magnetic resonance imaging can detect spinal intradural arachnoid cysts preoperatively, intraoperative ultrasonography is useful for close analysis of their movement and pathology. Considering the dynamic compression mechanism revealed in this study, the authors think that an early operation should be performed for such cysts 12).
2014
Atypical intradural arachnoid cysts can be related to perineural injections and can cause symptoms of spinal stenosis. Its spontaneous vanishing is a very rare event, up to now reported by Mailleux et al. 13).
Ishi et al. present the even-more rare case of an intradural arachnoid cyst associated with syringomyelia at the same spinal level.
The patient was a 66-year-old man who presented with bilateral leg numbness and gait disturbance. Magnetic resonance imaging (MRI) revealed an intradural arachnoid cyst located dorsal to, and compressing, the thoracic spinal cord at the level of the 7th thoracic vertebra (Th 7). In addition, syringomyelia existed at the level of Th 8, slightly caudal to the intradural arachnoid cyst. We dissected the cyst but did not perform any surgical procedures for the syringomyelia. Post-operative MRI showed that the cyst had disappeared and the syringomyelia had spontaneously shrunk. The patient was discharged with improvement in his numbness and gait disturbance. 14).
2013
Occurrence of a spinal intradural arachnoid cyst after epiduroscopic neural decompression 15).
2012
Symptomatic spinal cord compression from an intradural arachnoid cyst with associated syrinx in a child 16).
Animals
Fifty-seven dogs were included in the study. The most common type of surgery was durectomy (28 dogs) followed by marsupialization (11 dogs), durotomy alone (seven dogs), shuntplacement (six dogs), and stabilization (five dogs). A higher proportion of intra-arachnoid shunt dogs became unable to walk in the immediate postoperative period (24 hours postsurgery) (4/6, 66%) compared to all dogs five of 57, 9% (2/7 durotomy alone, 3/28 durectomy alone). Of the nine dogs with immediate postoperative deterioration, seven had improved, walking without assistance, by 3 to 5 weeks postoperatively.
Clinical significance: This study does not identify an influence of surgical technique on short-term outcomes. Dogs with a thoracolumbar intra-arachnoid diverticulum that undergo a shunt placement are likely to deteriorate neurologically in the immediate 24-hour postoperative period but appear to improve by 3 to 5 weeks after surgery. Further work is required to evaluate whether one surgical technique is superior for preventing or reducing long-term relapse 17)
Cho EJ, Jeon K, Kim YH, Moon DE. Occurrence of a spinal intradural arachnoid cyst after epiduroscopic neural decompression. Korean J Anesthesiol. 2013 Sep;65(3):270-2. doi: 10.4097/kjae.2013.65.3.270. PubMed PMID: 24101965; PubMed Central PMCID: PMC3790042.
Ishi Y, Aoyama T, Kurisu K, Hida K, Houkin K. [Intradural arachnoid cyst associated with syringomyelia: a case report]. No Shinkei Geka. 2014 May;42(5):467-72. Japanese. PubMed PMID: 24807552.
Yoo M, Lee CH, Kim KJ, Kim HJ. A case of intradural-extramedullary form of primary spinal cysticercosis misdiagnosed as an arachnoid cyst. J Korean Neurosurg Soc. 2014 Apr;55(4):226-9. doi: 10.3340/jkns.2014.55.4.226. Epub 2014 Apr 30. PubMed PMID: 25024830; PubMed Central PMCID: PMC4094751.
Bustos JA, Pretell EJ, Llanos-Zavalaga F, Gilman RH, Del Brutto OH, Garcia HH, et al. Efficacy of a 3-day course of albendazole treatment in patients with a single neurocysticercosis cyst. Clin Neurol Neurosurg. 2006;108:193–194.
Su DK, Ebenezer S, Avellino AM. Symptomatic spinal cord compression from an intradural arachnoid cyst with associated syrinx in a child: case report. Pediatr Neurosurg. 2012;48(4):236-9. doi: 10.1159/000348885. Epub 2013 Apr 18. PubMed PMID: 23615079.
Jones B, Behr S, Shaw T, Cappello R, Jeffery N, Liebel FX, Harcourt-Brown T. Surgical techniques used in the management of intra-arachnoid diverticula in dogs across four referral centres and their immediate outcome. J Small Anim Pract. 2022 Feb 9. doi: 10.1111/jsap.13486. Epub ahead of print. PMID: 35137433.
Because spinal meningiomas are infrequently encountered in any one center, a large portion of the literature relating to spinal meningiomas consists of case reports or case series 1)
In The Surveillance, Epidemiology and End Results, the age-adjusted incidence rate was 0.37 cases per 1,000,000 person-years between 2004 and 2016. Spinal meningiomas represented 4.25% of all meningiomas. A total of 4204 patients with spinal meningiomas were included in the study. Most of the patients were white and diagnosed at 60-69 years of age, and the female:male ratio was 4:1. Most of the tumors were benign and less than 3 cm in size. The most common pathological type was psammomatous meningioma. Surgery was the first choice of treatment for patients with spinal meningiomas. Male and pediatric patients were more vulnerable to borderline or malignant spinal meningiomas. Survival analysis showed that married, female, and younger patients with benign meningiomas had better overall survival than their counterparts 2).
Approximately 1000 spinal meningiomas were diagnosed in the United States per year, and the incidence was relatively stable. Advanced age, female sex, Asian Pacific Islander and Caucasian race, and Hispanic ethnicity were all associated with an increased incidence of spinal meningioma. The study of represents the most comprehensive evaluation of population-based descriptive epidemiology of spinal meningiomas in the United States to date 3).
Spinal meningiomas represent a significant fraction of all primary intradural spinal tumors and of all meningiomas. The results of a study of Westwick and Shamji established the association of lesion incidence and survival with sex, with a less frequent incidence in but greater mortality among males 4).
Amongst the intraspinal location, meningiomas account for 25% to 46% of primary spinal neoplasms, while the incidence of spinal meningiomas is 7.5% to 12.7% of all meningiomas
They have a peak incidence in the fifth and sixth decades. Interestingly, and unlike intracranial meningiomas, in the adult population, females are approximately ten times more commonly affected than males. In children, there does not appear to be a sex predilection.
There is an increased incidence of spinal meningiomas in patients with neurofibromatosis type 2 (NF2), and in fact in the paediatric population, meningiomas uncommonly occur outside of the setting of NF2.
Cao Y, Jiang Y, Liu C, Jin R, Jin Z, Hong X, Zhao L, Zhao G, Wang Y. Epidemiology and survival of patients with spinal meningiomas: A SEER analysis. Eur J Surg Oncol. 2021 Jan 22:S0748-7983(21)00039-1. doi: 10.1016/j.ejso.2021.01.012. Epub ahead of print. PMID: 33546961.
Kshettry VR, Hsieh JK, Ostrom QT, Kruchko C, Benzel EC, Barnholtz-Sloan JS. Descriptive Epidemiology of Spinal Meningiomas in the United States. Spine (Phila Pa 1976). 2015 Aug 1;40(15):E886-9. doi: 10.1097/BRS.0000000000000974. PMID: 25996535.
Westwick HJ, Shamji MF. Effects of sex on the incidence and prognosis of spinal meningiomas: a Surveillance, Epidemiology, and End Results study. J Neurosurg Spine. 2015 Sep;23(3):368-73. doi: 10.3171/2014.12.SPINE14974. Epub 2015 May 29. PMID: 26023898.
Zhan Z, Yan X, Nie W, Ding Y, Xu W, Huang H. Neurofibroma and Meningioma within a Single Dumbbell-Shaped Tumor at the Same Cervical Level without Neurofibromatosis: a Case Report and Literature Review. World Neurosurg. 2019 Jun 26. pii: S1878-8750(19)31788-7. doi: 10.1016/j.wneu.2019.06.142. [Epub ahead of print] PubMed PMID: 31254713.
A nontraumatic acute spontaneous spinal subdural hematoma (sSDH) is a rare complication after spinal surgery. Although an sSDH is often associated with anticoagulation therapy, vascular malformations, or lumbar puncture, the pathogenesis of nontraumatic spontaneous sSDH remains unclear 1)
Spontaneous spinal subdural hematoma after anticoagulation therapy
In the majority of cases, spontaneous hematomas are idiopathic. However, when attributed to anticoagulation therapy coumarins are more common than direct factor Xa inhibitors such as apixaban. Previous reports have linked direct factor Xa inhibitors with intracranial subdural hematomas much more frequently than spinal subdural hematomas. The manifestation of severe neurological deficits, such as sensorimotor disturbances and loss of sphincter control, is common and is considered a surgical emergency 2).
An 82-year-old patient with a history of ischemic heart disease and atrial fibrillation under acenocoumarol was admitted to emergency department with sudden onset of paraplegia and intense back pain associated with urinary incontinence and anal sphincter disorder. On examination his lower limb power was MRC grade 0 out of 5 in all ranges of movement bilaterally and a complete bilateral anesthesia reaching the T12 dermatome was noted. Biological test results showed an International Normalized Ratio at 10. Magnetic resonance imaging revealed a posteriorly located spinal hematoma at T12 level, measuring 36 mm with spinal cord compression. After correction of hemostasis disorders the patient was admitted to the operating room for a T11-L1 laminectomy with evacuation of the subdural hematoma. Muscle power showed a gradual improvement in the lower limbs estimated at 3/5 with regression of sphincter disorders but unfortunately a sequellar sensory impairment persisted.
SSH is a rare situation of acenocoumarol bleeding incident, it should be evoked in any patient treated by this molecule with signs of spinal cord compression 3).
A case of a patient with a spontaneous spinal thoracic subdural hematoma secondary to apixaban use with loss of sphincter control and paraplegia. After 6 months of follow-up, the patient recovered completely 4).
Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma
Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative Case and provide a systematic review of S-SDH in the setting of SAH. METHODS:
A systematic literature review using PRISMA guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported Case. RESULTS:
Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram negative cases. Hunt Hess grade ranged from 1-4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. 8 patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin score ranged from 0-6, with mRS > 2 for 4 out of 12 patients. Patients with a poor clinical outcome (mRS > 2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs 7.6 days), use of antithrombotic medication, no diversion of CSF, and cervical or thoracic S-SDH. CONCLUSION:
S-SDH is an uncommon occurrence in the setting of aneurysmal SAH with better outcomes associated with lumbar location, delayed presentation, CSF diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in cases with delayed S-SDH and lack of significant neurological deficits. More reported cases will allow greater understanding of this clinical entity 5).
Treatment
Surgical intervention is recommended in patients presenting with severe neurologic deficits. Conservative treatment is a reasonable option for asymptomatic patients 6).
Case reports
Raymaekers et al. presented the case of an intradural hematoma after an extraforaminal surgery through the Wiltse approach for an extraforaminal disk herniation at L5/S1. This 58-year-old woman experienced hypoesthesia and progressive motor dysfunction in the left leg several hours postoperation. Urgent magnetic resonance imaging revealed an intradural hematoma at the L1/L2 to L2/L3 level in the ventral dural sac proximal to the surgical level. Surgical decompression was performed. There was no evidence of trauma, coagulopathy, or anticoagulation therapy. To our knowledge, this case is the first to report an acute sSDH proximal to the surgery level after an extraforaminal spinal surgery through the Wiltse approach for an extraforaminal disk herniation. It illustrates that attentive postoperative neurologic monitoring, even in the absence of intraoperative irregularities, remains important to diagnose and treat this complication at the early stage 7)
A 55-year-old woman without malignancy or coagulopathy history presented with progressive low back pain for the past 2 weeks. Progressive bilateral leg weakness happened 1 week ago. On the day she called for help, she presented with bilateral leg grade 2 muscle power and generalized back pain. There was no headache or meningeal sign. An absent bilateral knee reflex was found. Magnetic resonance imaging showed a space-occupying lesion at the T2-T6 and T12-L1 levels in the ventral and dorsal spinal canal, leading to cord compression. Due to rapid neurologic function deterioration, emergent T12-L1 laminectomy was performed. We found a T12-L1 tense dura sac with subdural hematoma ventral to the cord. Removal of the SDH was performed. T2-T6 levels were treated conservatively. She returned ambulant 1 week after operation. Magnetic resonance images at 3 months and 1 year later showed the SDH being absorbed and replaced by adhesive arachnoid cysts along the whole T and L spine. However, these lesions are asymptomatic for at least 2 years 8).
Sanchez et al. reported a case of Reverse Takotsubo Cardiomyopathy in an otherwise healthy 23-year-old man presenting with back pain, urinary retention, bradycardia, and hypertension. Troponin levels and brain natriuretic peptide (BNP) were elevated, and echocardiogram revealed an ejection fraction (EF) of less than 20%. In addition, MRI demonstrated a spinal subdural hematoma from T1-S1 with no cord compression. Repeated echocardiogram demonstrated an EF of 20-25% with a reverse Takotsubo pattern of cardiomyopathy. With supportive care, his clinical picture improved with normalization of cardiac enzyme and BNP values. This case represents a r-TTC presenting as heart failure in a young, apparently healthy male likely incited by a spinal subdural hematoma. To our knowledge, it is the first of its kind reported 9).
A 7-yr old girl presented to Neurology Department, Mofid Hospital, ShahidBeheshti University of Medical Sciences, Tehran, Iran with limping and pain in lower extremities and acute paraplegia without history of direct trauma. The patient had muscle weakness in lower limbs and was unable to bear weight. Deep Tendon Reflexes (DTR) in lower extremities had increased. Her MRI showed spinal subdural hematoma we reextended from T2 to T6. We performed laminectomy from T2 to T5 and about 70 cc of subdural hematoma was evacuated. One month after the surgery, the patient’s neurological deficit resolved completely. The results showed the pivotal role of attention to clinical manifestation in acute spinal subdural hematoma and early diagnosis to prevent irreversible neurologic complication 10)
Spinal subdural hematoma in pediatric nonaccidental trauma 11)
A case of spontaneous, atraumatic subdural hematoma involving the thoracic region in an 80-year-old woman on warfarin is reported. The patient presented with gross motor and sensory loss, delayed onset of incontinence, and no other symptoms. An MRI suggested an epidural hematoma concentrated around the T4-T9 levels. She was taken emergently to the OR approximately 30 hours after the initial onset of symptoms for a T3-T11 laminectomy. No epidural hematoma was noted. However, discoloration and bulging of the thecal sac were noted, and the dura was incised longitudinally from T2 to T10 revealing an expansive jelly-like blood clot which was evacuated. Postoperatively, the patient had regained 1/2 sensory function in the bilateral lower extremities. At the 2-week mark, the patient was still incontinent and showed 2/2 sensory and 2/5 motor functions in select muscle groups in her bilateral lower extremities. Completely nontraumatic, spontaneous subdural hematomas of the spine are very rare, and early surgical decompression within 24 hours from symptom onset may allow neurological recovery. Large extensive laminectomies up to 10 thoracic levels have been shown to be safe and effective in a few cases, including our case 12).
Cases of non-traumatic spinal subdural hematoma accompanied by intracranial hemorrhage are even more rare. There are a few reports of spontaneous spinal subdural hematoma with concomitant intracranial subdural or subarachnoid hemorrhage, but not with intracerebral hemorrhage. Especially in a case of Lee et al., the evaluation and diagnosis were delayed because the spontaneous intracerebral hemorrhage accompanying the unilateral spinal subdural and subarachnoid hemorrhages caused hemiplegia. They reported a case of spinal subdural and subarachnoid hemorrhage with concomitant intracerebral hemorrhage, for the first time, with a relevant literature review 14).
A 76-year-old woman with a spinal subdural hematoma (SDH) was presented with severe back pain without headache. Magnetic resonance imaging (MRI) performed 4 days after onset showed SDH extending from Th2 to L3. She was diagnosed with spontaneous SDH without neurological manifestation, and conservative treatment was selected. Transient disturbance of orientation appeared 7 days after onset. Small subarachnoid hemorrhage (SAH) was detected on head CT, and strict antihypertensive therapy was started. Symptoms changed for the better. Back pain disappeared 4 weeks after onset. On follow-up MRI at 6 months after onset, the SDH had been resolved spontaneously. Although adhesive arachnoiditis was observed at Th4-6, the recurrence of clinical symptoms was not observed at one year and a half after onset. Spinal subdural space is almost avascular; a hematoma in a subdural space is considered to come from a subarachnoid space when it is a lot. A hemorrhage in subarachnoid space was flushed by cerebral spinal fluid; hematoma or arachnoiditis was not formed in general. In this case, hemorrhage was a lot and expansion of SDH was large enough to cause cranial SAH and arachnoiditis. But longitudinally expanded SDH did not show neurological manifestation and resolved spontaneously 15).
A 38-year-old male patient presented with sudden lower back and bilateral leg pain.
A magnetic resonance imaging (MRI) scan on the third day after the onset of symptoms revealed a subdural hematoma from L1 to S1, presenting as hyperintensities on T1 weighted sequences and hypointensities to isointensities on T2 weighted sequences.
Laminectomy and subdural evacuation were performed immediately.
An abnormal ligamentum flavum was observed intraoperatively. A histological examination revealed extravasation of blood in the degenerated ligamentum flavum. Postoperatively, the lower limb pain improved immediately. At the 6-month follow-up, the pain and numbness of the lower limb disappeared, and the muscle strength of both legs recovered completely with normal gait.
Spontaneous SSDH with ligamentum flavum hematoma was caused by a sudden increase of intravenous pressure, resulting from a marked surge in the intra-abdominal or intrathoracic pressure. Consecutive MRI scans provided valuable information, leading to a diagnosis of spontaneous SSDH 16).
Oh et al. presented a case of acute nontraumatic SSDH presenting with transient left hemiplegia for 4 hours. A magnetic resonance imaging study of cervical spine confirmed SSDH with C3-6 cervical cord compression at the left side. The patient had conservative management without recurrence. Although hemiplegia is an unusual clinical manifestation of SSDH, it should be differentiated from that of cerebrovascular origin promptly. Conservative management may be an alternative therapeutic option for selective cases with transient neurological deficits 17).
Raymaekers V, Beck T, Goebel S, Janssens F, Van den Branden L, Menovsky T, Plazier M. An Acute Spinal Intradural Hematoma after an Extraforaminal Wiltse Approach: A Case Report and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg. 2020 Oct 21. doi: 10.1055/s-0040-1714432. Epub ahead of print. PMID: 33086421.
Aissa I, Elkoundi A, Andalousi R, Benakrout A, Chlouchi A, Moutaoukil M, Laaguili J, Bensghir M, Balkhi H, Lalaoui SJ. Unusual localization of bleeding under acenocoumarol: Spinal subdural hematoma. Int J Surg Case Rep. 2019;59:15-18. doi: 10.1016/j.ijscr.2019.04.053. Epub 2019 May 10. PubMed PMID: 31100481; PubMed Central PMCID: PMC6522769.
Rothrock RJ, Li AY, Rumsey J, Fifi JT, Kellner CP, Roonprapunt C. Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature. World Neurosurg. 2019 May 16. pii: S1878-8750(19)31343-9. doi: 10.1016/j.wneu.2019.05.069. [Epub ahead of print] Review. PubMed PMID: 31103768.
Sanchez K, Glener S, Esplin NE, Okorie ON, Parikh A. A Case of Reverse Takotsubo Cardiomyopathy Incited by a Spinal Subdural Hematoma. Case Rep Neurol Med. 2019 Jul 22;2019:9285460. doi: 10.1155/2019/9285460. eCollection 2019. PubMed PMID: 31428488; PubMed Central PMCID: PMC6679891.
Farzan A, Pourbakhtyaran E, Moosavian T, Moosavian H. Spinal Subdural Hematomas in a Normal Child without Trauma History: A Case Report. Iran J Child Neurol. 2019 Summer;13(3):121-124. PubMed PMID: 31327977; PubMed Central PMCID: PMC6586447.
Arain AR, Moral M, Shams S, Desai K, Kalsa K. Atypical Presentation of Atraumatic Spinal Subdural Hematoma Associated with Warfarin: A Case Report and Review of the Literature. Case Rep Orthop. 2019 May 20;2019:4037916. doi: 10.1155/2019/4037916. eCollection 2019. PubMed PMID: 31236299; PubMed Central PMCID: PMC6545747.
Benyaich Z, Laghmari M, Lmejjati M, Aniba K, Ghannane H, Benali SA. Acute lumbar spinal subdural hematoma inducing paraplegia after lumbar spinal manipulation: A case report and literature review. World Neurosurg. 2019 May 9. pii: S1878-8750(19)31275-6. doi: 10.1016/j.wneu.2019.05.002. [Epub ahead of print] PubMed PMID: 31078801.
Lee Y, Lim J, Han S, Choi SW, Youm JY, Koh HS. Spontaneous Spinal Subdural and Subarachnoid Hemorrhage with Concomitant Intracerebral Hemorrhage: A Case Report. Korean J Neurotrauma. 2019 Apr 19;15(1):34-37. doi: 10.13004/kjnt.2019.15.e7. eCollection 2019 Apr. PubMed PMID: 31098347; PubMed Central PMCID: PMC6495584.
Go T, Tsutsui T, Iida Y, Fukutake K, Fukano R, Ishigaki K, Tsuchiya K, Takahashi H. A Case of Spontaneous Spinal Subdural Hematoma Complicated by Cranial Subarachnoid Hemorrhage and Spinal Adhesive Arachnoiditis. Case Rep Orthop. 2019 Mar 13;2019:7384701. doi: 10.1155/2019/7384701. eCollection 2019. PubMed PMID: 31001442; PubMed Central PMCID: PMC6436331.
Li X, Yang G, Wen Z, Lou X, Lin X. Surgical treatment of progressive cauda equina compression caused by spontaneous spinal subdural hematoma: A case report. Medicine (Baltimore). 2019 Mar;98(12):e14598. doi: 10.1097/MD.0000000000014598. PubMed PMID: 30896615.
Lumbar puncture is a useful diagnostic and treatment tool. Although serious events are seldom, they can be detrimental. A precaution not to underestimate such events in practicing lumbar, especially in patients with suboptimum coagulation state. Image-guided procedure can be useful and should be considered in appropriately selected patients 1).
In a Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture 2).
It is estimated that approximately 4% of symptomatic spinal hematomas are related to traumatic LP. They are commonly located inclusively with the epidural space in 75% of the cases, whereas subarachnoid hemorrhage and spinal subdural hematoma can be found in 15.7% and 4.1%, respectively. Multi-compartmental spinal hematomas are rare and thought to present in 0.33% 3).
In clinical practice, few carry out postprocedural investigation for spinal hematoma unless the patient reports sensory or motor changes after the procedure. In a meta-analysis, approximately 85% of symptomatic spinal hematomas required surgical intervention 4)
Surgery is indicated for symptomatic patients with reported complete neurological recovery in almost 40%. The timing of surgery is vital and associated with improved neurological outcome when done in less than 36 hours 5).
Nevertheless, symptomatic spinal hematoma is a critical condition and we emphasize that surgical intervention should be considered at a low threshold for urgent decompression to optimize overall clinical outcome. Coagulopathy is an important risk factor that should not be underestimated in planning for LP. The presence of pre-existing coagulopathy was found to be a significant poor prognostic factor regardless of surgical intervention. Therefore, an early investigation with spinal MRI should be obtained to rule out an evolving spinal hematoma. Mortality was reported high in patients with compressive cervical spinal epidural hematomas and cardiovascular disease 6).
Case reports
A case for a patient with Burkitt lymphoma who presented with mild neuroaxial symptoms. An urgent cerebrospinal fluid sample was required which was taken after correcting his platelets count to 53.4 × 109/L. He developed a massive multi-compartmental thoracolumbar hematoma with acute cauda equine syndrome requiring surgical intervention. Despite aggressive management, he remained permanently paraplegic with functional status that negatively affected his overall outcome 7).
Bodilsen J, Mariager T, Vestergaard HH, Christiansen MH, Kunwald M, Lüttichau HR, Kristensen BT, Bjarkam CR, Nielsen H. Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy. JAMA. 2020 Oct 13;324(14):1419-1428. doi: 10.1001/jama.2020.14895. PMID: 33048155.
Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery. 1996 Sep;39(3):494-508; discussion 508-9. doi: 10.1097/00006123-199609000-00012. PMID: 8875479.
