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Sangondimath G, George J, Rehman T F, Singh A, Guha M. Unilateral Neurological Deficit Due to Spinal Epidural Hematoma Following Midline-Sparing Spine Surgery: A Case Report. Cureus 2023; 15:e50788. [PMID: 38239548 PMCID: PMC10795855 DOI: 10.7759/cureus.50788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
Symptomatic spinal epidural hematoma (SEH) is a rare but well-documented complication in spine surgery, often associated with risk factors such as abnormal coagulation parameters, low platelets, excessive epidural bleeding, and inadequate hemostasis. While bilateral SEH is frequently described in the literature, unilateral SEH following spine surgery is seldom reported. We present a unique case of a unilateral neurological deficit resulting from an SEH following midline-sparing spine surgery due to unilateral drain placement in an 80-year-old male patient without comorbidities and normal coagulation parameters. Subsequent evacuation of the hematoma was done leading to gradual recovery of neurology. This emphasizes the importance of bilateral drain placement in such midline-sparing spine surgeries. This report underscores the significance of early SEH diagnosis and intervention, providing valuable insights into preventive measures and the need for a high index of suspicion in managing this potentially debilitating complication.
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Affiliation(s)
| | - Jomin George
- Spine Surgery, Indian Spinal Injuries Center, Delhi, IND
| | - Fazal Rehman T
- Spine Surgery, Indian Spinal Injuries Center, Delhi, IND
| | - Amlan Singh
- Spine Surgery, Indian Spinal Injuries Center, Delhi, IND
| | - Mayukh Guha
- Spine Surgery, Indian Spinal Injuries Center, Delhi, IND
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Xu W, Guo J, Zhu J, Zhao X, Yasaman I, Chen J, Wang J, Fan S, Fang X. Delayed postoperative spinal epidural hematoma after anterior cervical discectomy and fusion: A case report. Front Surg 2022; 9:1005462. [PMID: 36225220 PMCID: PMC9549240 DOI: 10.3389/fsurg.2022.1005462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative spinal epidural hematoma (POSEH) causes rapid neurological deficits within 24 h following the operation and can be fatal. However, some POSEH symptoms manifest three days after the operation, also known as delayed POSEH (DPOSEH). Little attention has been provided upon DPOSEH owing to its rare incidence, resulting in serious consequences upon occurrence. To date, no cases of delayed POSEH after anterior cervical surgery have been reported.Case presentationWe describe a case of DPOSEH that presented with delayed neurological deficits on the fifth day after anterior cervical discectomy and fusion (ACDF) surgery. Methylprednisolone was administered but showed no efficacy. MR revealed low T1 and strip long T2 signals located behind discs. After emergency surgical decompression, the patient's muscle strength returned to the preoperative state. However, his muscle strength decreased again on the seventh postoperative day, and the patient's family refused further surgery. Nine months after ACDF, the patient died of septic shock and respiratory failure.ConclusionsDPOSEH can occur after three days or more following anterior cervical surgery; hence, monitoring of neurological function is suggested to be extended. Complete evaluation of risk factors, timely recognition, and differentiation of neurological symptoms are required for spine surgery. In the case of DPOSEH, methylprednisolone can be administered reasonably during the transition period. However, if there is no resolution of symptoms, emergency surgery should be performed as soon as possible.
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Affiliation(s)
- Wenbin Xu
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Jiandong Guo
- Department of Orthopaedics, Hangzhou Ninth People's Hospital, Hangzhou, China
| | - Jinjin Zhu
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Xing Zhao
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | | | - Jian Chen
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
| | - Jiying Wang
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
| | - Shunwu Fan
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
| | - Xiangqian Fang
- Department of Orthopedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang, Hangzhou, China
- Correspondence: Xiangqian Fang Shunwu Fan Jiying Wang
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Delayed Onset Postoperative Spinal Epidural Hematoma after Lumbar Spinal Surgery: Incidence, Risk Factors, and Clinical Outcomes. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8827962. [PMID: 33426075 PMCID: PMC7775149 DOI: 10.1155/2020/8827962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/12/2020] [Accepted: 12/20/2020] [Indexed: 02/06/2023]
Abstract
Background Posterior spinal epidural haematoma (PSEH) often develops within 24 hours after surgery. On rare occasions, PSEH occurs after 3 days and up to two weeks and is classified as delayed-onset PSEH. Due to its rarity, previous studies have only described the clinical features, whereas risk factors have not been assessed. Methods Patients who developed PSEH requiring haematoma evacuation between December 2013 and January 2020 were included and divided into the early-onset (group A) and delayed-onset (group B) groups based on the time of symptom onset (>72 hours). For each PSEH patient, 3 controls (group C) who did not develop PSEH in the same period were randomly selected. Clinical features were compared among the three groups, and multiple logistic regression analysis was performed to identify the risk factors for groups A and B. Results Thirty-two patients (0.35%) were identified as having early-onset PSEH (occurring at 10.68 ± 11.5 h), and 15 (0.16%) patients had delayed-onset PSEH (occurring at 130.60 ± 61.78 h). When comparing groups A and B, group A showed a higher rate of multilevel procedures, lower drainage, lower APTT, and higher JOA score at discharge. Multiple logistic regression analysis identified multilevel procedures (OR: 5.62, 95% CI: 1.84-17.25), postoperative systolic blood pressure (SBP) (OR: 1.10, 95% CI: 1.06-1.15), and abnormal coagulation (OR: 5.68, 95% CI: 1.74-18.52) as independent risk factors for group A, whereas postoperative SBP (OR: 1.10, 95% CI: 1.04-1.16) and previous spinal surgery (OR: 4.74, 95% CI: 1.09-20.70) at the same level were risk factors for group B. Conclusions Our study revealed that the overall incidence of delayed-onset PSEH was 0.16% in posterior lumbar spinal surgery and that its risk was different from that of early-onset PSEH. If patients with such risk factors develop neurological deficits 3 days after initial surgery, surgeons should be aware of the possibility of delayed-onset PSEH.
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Moorthy V, Wang JX, Tang JH, Oh JYL. Postoperative spinal epidural hematoma following therapeutic anticoagulation: case report and review of literature. JOURNAL OF SPINE SURGERY 2020; 6:743-749. [PMID: 33447677 DOI: 10.21037/jss-20-636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
While the incidence and risk factors of pulmonary embolism (PE) and deep vein thrombosis (DVT) following spinal surgery have been well studied, the treatment of such thromboembolic disease in patients after spine surgery remains controversial. When initiating therapeutic anticoagulation after spine surgery, clinicians must weigh the catastrophic risk of a PE against the risk of bleeding complications associated with anticoagulation therapy. Here we report the case of a 56-year-old male who presented with symptoms of spinal cord compression secondary to metastatic renal cell carcinoma (RCC). An inferior vena cava (IVC) filter was inserted preoperatively and urgent decompression at the thoraco-lumbar region was performed. Therapeutic clexane was started on postoperative day (POD) 7 and he was discharged. On POD 8, he was readmitted following acute bilateral lower limb paralysis. Magnetic resonance imaging (MRI) revealed a large posterior spinal epidural hematoma with severe compression of the conus at L1 level. Urgent posterior decompression was performed but subsequent recovery was slow and incomplete. His power improved gradually over the right lower limb with attainment of grade 4/5 motor power but still had hemiparesis on his left lower limb upon discharge out of hospital. This case highlights the risk of starting therapeutic anticoagulation following spinal surgery. Prior to starting treatment, the clinician must consider the appropriate dose, timing and alternatives available to avoid unnecessary complications.
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Affiliation(s)
- Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | | | - Jun Han Tang
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Chen J, Shao XX, Sui WY, Yang JF, Deng YL, Xu J, Huang ZF, Yang JL. Risk factors for neurological complications in severe and rigid spinal deformity correction of 177 cases. BMC Neurol 2020; 20:433. [PMID: 33246421 PMCID: PMC7697368 DOI: 10.1186/s12883-020-02012-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 07/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Difficult procedures of severe rigid spinal deformity increase the risk of intraoperative neurological injury. Here, we aimed to investigate the preoperative and intraoperative risk factors for postoperative neurological complications when treating severe rigid spinal deformity. METHODS One hundred seventy-seven consecutive patients who underwent severe rigid spinal deformity correction were assigned into 2 groups: the neurological complication (NC, 22 cases) group or non-NC group (155 cases). The baseline demographics, preoperative spinal cord functional classification, radiographic parameters (curve type, curve magnitude, and coronal/sagittal/total deformity angular ratio [C/S/T-DAR]), and surgical variables (correction rate, osteotomy type, location, shortening distance of the osteotomy gap, and anterior column support) were analyzed to determine the risk factors for postoperative neurological complications. RESULTS Fifty-eight patients (32.8%) had intraoperative evoked potentials (EP) events. Twenty-two cases (12.4%) developed postoperative neurological complications. Age and etiology were closely related to postoperative neurological complications. The spinal cord functional classification analysis showed a lower proportion of type A, and a higher proportion of type C in the NC group. The NC group had a larger preoperative scoliosis angle, kyphosis angle, S-DAR, T-DAR, and kyphosis correction rate than the non-NC group. The results showed that the NC group tended to undergo high-grade osteotomy. No significant differences were observed in shortening distance or anterior column support of the osteotomy area between the two groups. CONCLUSIONS Postoperative neurological complications were closely related to preoperative age, etiology, severity of deformity, angulation rate, spinal cord function classification, intraoperative osteotomy site, osteotomy type, and kyphosis correction rate. Identification of these risk factors and relative development of surgical techniques will help to minimize neural injuries and manage postoperative neurological complications.
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Affiliation(s)
- Jian Chen
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Xie-Xiang Shao
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Wen-Yuan Sui
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Jing-Fan Yang
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Yao-Long Deng
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Jing Xu
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China
| | - Zi-Fang Huang
- Department of Orthopaedic Surgery, the 1st Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jun-Lin Yang
- Spine Surgery Center, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China.
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Chung WH, Tan RL, Chiu CK, Kwan MK, Chan C. Delayed Post-operative Spinal Epidural Haematoma after Posterior Spinal Surgery: Report of Two Cases. Malays Orthop J 2020; 14:170-173. [PMID: 33403080 PMCID: PMC7752003 DOI: 10.5704/moj.2011.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.
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Affiliation(s)
- W H Chung
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - R L Tan
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - C K Chiu
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - M K Kwan
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - Cyw Chan
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
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Komatsu J, Sato K, Iwabuchi M, Fukuda H, Kusano K, Kaneko K, Shirado O. Recovery of paraplegia following postoperative epidural hematomas in lumbar canal stenosis surgery by closed kinetic chain (CKC) exercises: A case report. Medicine (Baltimore) 2019; 98:e15670. [PMID: 31096499 PMCID: PMC6531241 DOI: 10.1097/md.0000000000015670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
RATIONALE A postoperative spinal epidural hematoma (PSEH) is among the most devastating complications following spine and spinal cord surgery, and it should be considered before performing microendoscopic decompression as part of minimally invasive surgery, since early recovery is one of the advantages of this procedure. PATIENT CONCERNS A 70-year-old woman with lumbar spinal stenosis at L4-5 underwent tubular surgery with the assistance of endoscopic laminectomy (MEL), but 2 days after the surgery, the patient noticed decreased lower limb sensation and power of the right leg, and she developed numbness from the level of L5 and weakness from the L4, 5 myotome distally. DIAGNOSES An epidural hematoma at the L4-5 surgical site was found on magnetic resonance imaging of the lumbar spine and evacuated operatively. This rare complication appears to be the result of a PSEH. In the present case, complete neurological recovery was not achieved, despite rapid surgery. INTERVENTIONS The patient's course and physical therapy, which focused on attitude maintenance practice and muscle-strengthening exercise of the closed kinetic change (CKC) type from the early stage of paraplegia, were specifically examined. OUTCOMES The patient recovered complete motor function with attitude maintenance practice and muscle strengthening exercises after 3 months. CKC exercise in particular may contribute to improving caudal muscle weakness, including the L4, 5 innervated area (e.g., tibialis anterior [TA], extensor hallucis longus [EHL], flexor hallucis longus [FHL], gastrocnemius [GC], etc.). LESSONS Prevention of PSEH is needed to not only avoid neurological deterioration, but also avoid delaying the patient's recovery. CKC exercise may contribute to improving the prolonged paralysis associated with a PSEH. Future studies should involve larger numbers of patients to evaluate the clinical features of PSEH and treatment by rehabilitation with more effective muscle exercises and stretches.
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Affiliation(s)
- Jun Komatsu
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
- Department of Medicine for Motor Organs, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Keita Sato
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
| | - Masumi Iwabuchi
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
| | - Hironari Fukuda
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
| | - Keigo Kusano
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
| | - Kazuo Kaneko
- Department of Medicine for Motor Organs, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Osamu Shirado
- Department of Orthopaedic and Spinal Surgery, The AMEC (Aizu Medical Center) of Fukushima Medical University, Aizu-Wakamatsu City, Fukushima
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The Incidence, Clinical Features, and a Comparison Between Early and Delayed Onset of Postoperative Spinal Epidural Hematoma. Spine (Phila Pa 1976) 2019; 44:420-423. [PMID: 30095797 DOI: 10.1097/brs.0000000000002838] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective observational study. OBJECTIVE To investigate the incidence and clinical features of symptomatic postoperative spinal epidural hematoma (PSEH) with regard to spinal level and to compare early and delayed onset cases. SUMMARY OF BACKGROUND DATA PSEH is a serious complication of spinal surgeries. The difference in clinical manifestations between early and delayed PSEH remains unclear. METHODS Patients who underwent spinal surgeries between 1999 and 2013 at our institution, were reviewed through their medical records. For patients with PSEH, the incidence, duration to onset, duration from onset to evacuation, symptoms, recovery rate (American Spinal Injury Association grade), neurological outcomes, comorbidities, and preoperative use of anticoagulant drugs were examined. We next compared patients with early onset PSEH (onset until day 3) versus delayed onset (onset day 4 or later) regarding these clinical factors. RESULTS Fourteen patients (0.42%, 14/3371) developed symptomatic PSEH. Initial symptoms were observed between 0 and 7 days (mean 2.6 ± 2.4 d) and almost half (43%, 6/14) occurred during the delayed phase (mean 5.0 ± 1.1 d postsurgery). Paralysis was the predominant symptom in patients with cervical and thoracic surgeries (100%, 6/6), whereas severe pain was most frequent in patients with lumbar procedures (63%, 5/8) (P = 0.019). No significant differences were identified between early and delayed groups. Neurological outcome was good in 10 cases, partial in two cases, and poor in two cases. CONCLUSION The frequency was consistent in every spinal region, and the symptoms due to PSEH were correlated with spinal level. Almost half the cases were diagnosed after a delay (day 4 or later), which supports the necessity to follow up patients with spinal surgeries more carefully for a week or so and to educate patients and comedical staff about the possibility of delayed hematoma disorders in order not to defer timely intervention. LEVEL OF EVIDENCE 4.
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Davidoff CL, Rogers JM, Simons M, Davidson AS. A systematic review and meta-analysis of wound drains in non-instrumented lumbar decompression surgery. J Clin Neurosci 2018; 53:55-61. [PMID: 29680443 DOI: 10.1016/j.jocn.2018.04.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 04/09/2018] [Indexed: 02/03/2023]
Abstract
Wound drains are routinely used in lumbar decompressive surgery (LDS). However, it remains unclear whether this practice helps to prevent symptomatic epidural hematoma formation and associated complications, particularly following non-instrumented procedures. A systematic review and meta-analysis was therefore completed to critically appraise the literature. The search protocol was conducted using the Ovid MEDLINE, EMBASE, Scopus, Cochrane Library, and Google Scholar databases. Articles meeting the following criteria were included: (i) examined patients undergoing LDS; (ii) included cases receiving post-operative wound drains; (iii) detailed adverse outcomes including symptomatic epidural hematomas or wound infection; and (iv) were published in English in a peer-reviewed journal. Pooled risk differences (RD) for adverse outcomes were calculated using Comprehensive Meta-Analysis software. Three Level 1b prospective randomized studies and five Level 2b retrospective cohort studies were included, from which 5327 cases were identified as having received a surgical drain and 773 were identified as having received no drainage following non-instrumented LDS. There was no difference between groups in the risk of symptomatic epidural hematoma (RD = 0.02; 95% CI -0.02 - 0.06, p = 0.28) or post-operative infection (RD = 0.00; 95% CI -0.01 - 0.01, p = 0.91). In conclusion, symptomatic epidural hematomas and infection are rare following non-instrumented LDS, with incidence rates unaffected by the routine use of wound drainage.
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Affiliation(s)
- Christopher L Davidoff
- Macquarie Neurosurgery, Macquarie University Hospital, Sydney, New South Wales 2109, Australia; Department of Neurosurgery, Nepean Hospital, Penrith, New South Wales 2750, Australia.
| | - Jeffrey M Rogers
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
| | - Mary Simons
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
| | - Andrew S Davidson
- Macquarie Neurosurgery, Macquarie University Hospital, Sydney, New South Wales 2109, Australia; Department of Neurosurgery, Nepean Hospital, Penrith, New South Wales 2750, Australia; Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales 2109, Australia
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Okazaki T, Nakagawa H, Hayase H, Irie S, Inagaki T, Saito O, Yamashina M, Nagahiro S, Saito K. Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures. Neurol Med Chir (Tokyo) 2018; 58:138-144. [PMID: 29415912 PMCID: PMC5929923 DOI: 10.2176/nmc.cr.2017-0052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Spontaneous and chronic epidural hematoma (SSEH) in the lumbar spine is rare, and idiopathic and chronic SSEH in the lumbar spine is extremely rare disease. Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. Definitive guidelines for management of this condition are not clear and surgical total evacuation was performed in most of the cases. Some authors reported the epidural bleeding originates in the rupture of Batson’s plexus due to a rise in intra-abdominal pressure, but the mechanism is not clearly clarified. We report a surgical case of idiopathic and chronic SSEH. A 61-year-old woman suffered a sudden onset of severe lumbar pain during sleep. She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5. This patient underwent the partial evacuation of the hematoma with partial hemilaminectomy on left at L2/3, resulting in immediate pain relief and resolution of symptoms and almost absorption of the hematoma within 1 week of the procedure. We presented this rare case and reviewed idiopathic and chronic epidural hematoma in the lumbar spine.
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Affiliation(s)
- Toshiyuki Okazaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital.,Department of Neurosurgery, Tokushima University
| | | | - Hitoshi Hayase
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Shinsuke Irie
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Toru Inagaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Osamu Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | | | | | - Koji Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
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Tomii M, Mizuno J, Kazama K, Matsushima T, Watanabe K. Delayed Postoperative Spinal Epidural Hematoma after Cervical Laminoplasty. NMC Case Rep J 2017; 5:35-38. [PMID: 29354337 PMCID: PMC5767485 DOI: 10.2176/nmccrj.cr.2017-0099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/06/2017] [Indexed: 01/30/2023] Open
Abstract
A 56-year-old man underwent cervical laminoplasty for cervical spondylosis. On the 7th postoperative day, he suddenly felt severe neck pain, and tetraplegia developed rapidly over 1.5 hrs. Computed tomography demonstrated a huge hematoma compressing the cervical spinal cord. Clot was evacuated 3 hrs after the onset of symptoms. The patient’s postoperative course was uneventful. His blood pressure could not be properly controlled in the perioperative period. Surgeons should keep in mind that delayed postoperative spinal epidural hematoma (DPSEH) can occur more than a week after surgery, and meticulous blood pressure control is important for more than a week after a spinal operation.
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Affiliation(s)
- Masato Tomii
- Department of Neurosurgery, Southern TOHOKU General Hospital, Iwanuma, Miyagi, Japan
| | - Junichi Mizuno
- Department of Neurosurgery, Southern TOHOKU General Hospital, Iwanuma, Miyagi, Japan
| | - Ken Kazama
- Department of Neurosurgery, Southern TOHOKU General Hospital, Iwanuma, Miyagi, Japan
| | - Tadao Matsushima
- Department of Neurosurgery, Southern TOHOKU General Hospital, Iwanuma, Miyagi, Japan
| | - Kazuo Watanabe
- Department of Neurosurgery, Southern TOHOKU General Hospital, Iwanuma, Miyagi, Japan.,Department of Neurosurgery, Southern TOHOKU Research Institute for Neuroscience, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
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Symptomatic extensive thoracolumbar epidural hematoma following lumbar disc surgery treated by single level laminectomy. Asian Spine J 2012; 6:152-5. [PMID: 22708022 PMCID: PMC3372553 DOI: 10.4184/asj.2012.6.2.152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 05/08/2011] [Accepted: 05/12/2011] [Indexed: 11/21/2022] Open
Abstract
Spinal epidural hematomas (SEHs) are rare complications following spine surgery, especially for single level lumbar discectomies. The appropriate surgical management for such cases remains to be investigated. We report a case of an extensive spinal epidural hematoma from T11-L5 following a L3-L4 discectomy. The patient underwent a single level L4. A complete evacuation of the SEH resulted in the patient's full recovery. When presenting symptoms limited to the initial surgical site reveal an extensive postoperative SEH, we propose: to tailor the surgical exposure individually based on preoperative findings of the SEH; and to begin the surgical exposure with a limited laminectomy focused on the symptomatic levels that may allow an efficient evacuation of the SEH instead of a systematic extensive laminectomy based on imaging.
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Carragee EJ, Golish SR, Scuderi GJ. A case of late epidural hematoma in a patient on clopidogrel therapy postoperatively: when is it safe to resume antiplatelet agents? Spine J 2011; 11:e1-4. [PMID: 21095164 DOI: 10.1016/j.spinee.2010.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/09/2010] [Accepted: 10/19/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of antiplatelet agents after coronary artery stent placement is currently recommended to prevent coronary stent obstruction. These patients may have concurrent disabling spinal stenosis and require spinal decompression. Resuming antiplatelet agents as soon as possible after spinal surgery is recommended. PURPOSE To describe a unique case of late postoperative epidural hematoma occurring with the use of clopidogrel. STUDY DESIGN A case report and review of the literature. METHODS The hospital chart, history, physical examination, and imaging of a single patient were reviewed. RESULTS A 59-year-old man underwent spinal decompression and fusion for neurogenic claudication with lumbar spinal stenosis and spondylolisthesis while managed on clopidogrel for prevention of thrombosis after cardiac stent placement. He developed a symptomatic epidural hematoma 12 days postoperatively, well outside the usual time frame for this complication. The patient was closely monitored, and lumbar radiculopathy resolved over the ensuing days. CONCLUSION After spinal surgery and resumption of antiplatelet therapy, the physician needs to maintain vigilance in observing patients for late postoperative complications such as epidural hematoma, which could have catastrophic consequences if not recognized in a timely manner.
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Affiliation(s)
- Eugene J Carragee
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA 94063-6342, USA
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Delayed Spinal Epidural Hematoma after En Block Spondylectomy for Vertebral Ewing's Sarcoma. Asian Spine J 2010; 4:118-22. [PMID: 21165315 PMCID: PMC2996623 DOI: 10.4184/asj.2010.4.2.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 03/15/2010] [Accepted: 03/18/2010] [Indexed: 01/30/2023] Open
Abstract
We report here on a case of a 23-year-old male who received en block spondylectomy for a vertebral Ewing's sarcoma at our hospital. Nine days after surgery, he presented with severe back pain and motor weakness of the lower extremities. Based on the physical examination and the computed tomography scan, he was diagnosed with acute cauda equina syndrome that was caused by compression from an epidural hematoma. His neurological functions recovered after emergency evacuation of the hematoma. This case showed that extensive surgery for a malignant vertebral tumor has a potential risk of delayed epidural hematoma and acute cauda equina syndrome and this should be treated with emergency evacuation.
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Sarubbo S, Garofano F, Maida G, Fainardi E, Granieri E, Cavallo MA. Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:1055-61. [PMID: 19859747 PMCID: PMC2899401 DOI: 10.1007/s00586-009-1175-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Indexed: 12/14/2022]
Abstract
Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.
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Affiliation(s)
- Silvio Sarubbo
- Division of Neurosurgery, Department of Neuroscience and Rehabilitation, S. Anna University Hospital, Ferrara, Italy.
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Postoperative spinal epidural hematoma resulting in cauda equina syndrome: a case report and review of the literature. CASES JOURNAL 2009; 2:8584. [PMID: 19830087 PMCID: PMC2740261 DOI: 10.4076/1757-1626-2-8584] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 06/27/2009] [Indexed: 01/30/2023]
Abstract
Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.
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Abstract
STUDY DESIGN Prospective clinical series with comparison to retrospectively collected data. OBJECTIVE To compare direct measures of postoperative hematoma volume against a new measure of hematoma effect on the thecal sac: the critical ratio. SUMMARY OF BACKGROUND DATA Asymptomatic epidural hematoma is common after lumbar surgery. Symptomatic patients demonstrate a typical progression from sharp peri-incisional pain to bilateral neurologic deficits. Little is known about what differentiates symptomatic and asymptomatic patients. Magnetic resonance imaging (MRI) measures of hematoma size or mass effect may correlate with postoperative symptoms. METHODS The study population consisted of 3 patient groups evaluated by MRI 2 to 5 days after lumbar decompression with or without fusion. Fifty-seven consecutive prospectively enrolled patients comprised the asymptomatic group. No patient developed severe postoperative pain or neurologic deficit. Search of our institutional database identified 4978 surgical patients within the last 24 months. Seventeen developed new postoperative symptoms. The painful group included 12 patients with severe peri-incisional pain without neurologic deficit. The cauda equina (CE) group included 5 patients with postoperative CE syndrome. Digital imaging software was used to calculate thecal sac cross sectional area on pre- and postoperative MRI at each level, hematoma volume, volume per level decompressed, and critical ratio for each patient. Critical ratio was defined as the smallest ratio of postoperative to preoperative cross sectional area within the lumbar spine. RESULTS.: The critical ratio was the only measure found to differ significantly (P < 0.05) among all 3 groups. Mean critical ratios were asymptomatic (0.8), painful (0.5), and CE (0.2). CONCLUSION The critical ratio correlates more closely with the presence or absence of postoperative symptoms than measures of hematoma volume, and is consistent with the clinical expectation that greater thecal sac compression may result in more severe symptoms. Few guidelines exist for postoperative lumbar MRI interpretation. The critical ratio is an important contribution.
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Keyoung HM, Kanter AS, Mummaneni PV. Delayed-onset neurological deficit following correction of severe thoracic kyphotic deformity. J Neurosurg Spine 2008; 8:74-9. [DOI: 10.3171/spi-08/01/074] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓There are many potential risks associated with spinal deformity correction procedures including transient and/or permanent neurological deficits. Typically, neurological deficits caused by the surgical correction of spinal kyphosis occur acutely during surgery or immediately after surgery. Delayed postoperative neurological deficits are extremely rare.
The authors report a case of delayed neurological deficit that occurred 48 hours after surgical correction of thoracic hyperkyphosis. An 18-year-old man with myotonic dystrophy presented with a 110° T7–L1 kyphosis. The patient underwent an uneventful two-stage correction procedure of the hyperkyphotic deformity. First, anterior discectomies and fusion were performed from T-7 to L-1 using rib autograft, and all segmental vessels were preserved. Subsequently, on the same day, the patient underwent posterior Smith–Petersen osteotomies and T7–L2 pedicle screw fixation. Intact somatosensory and motor evoked potentials were maintained throughout both operations. Postoperatively, he remained neurologically intact without sequelae for nearly 48 hours. On postoperative Day 2, the patient developed delayed monoplegia of the left leg and sensory level loss below T-10.
Medical management enabled complete reversal of the patient's monoplegia and sensory loss. At 2-year follow-up, the patient had no adverse neurological sequelae.
In this case, a delayed postoperative neurological deficit occurred following spinal hyperkyphosis correction. The authors discuss the possible etiological mechanisms behind this complication and suggest strategies for its management.
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Abstract
STUDY DESIGN Prospective clinical series. OBJECTIVE To determine the incidence, volume, and extent of postoperative epidural hematoma resulting in thecal sac compression, and to identify risk factors correlated with measured hematoma volumes. SUMMARY OF BACKGROUND DATA Risk factors for postoperative hematoma development have been retrospectively determined in small populations of symptomatic patients. A prospective study of hematoma characteristics and associated risk factors in a consecutive series of patients could significantly enhance our understanding of postoperative hematoma. METHODS Preoperative magnetic resonance imaging and clinical data on 13 pre- and intraoperative risk factors were prospectively collected on 50 consecutive patients undergoing lumbar decompression surgery with or without fusion. Postoperative magnetic resonance imagings were performed within 2 to 5 days of surgery. Thecal sac cross-sectional area was calculated at each disc space. Relative thecal sac compression due to hematoma was calculated at all levels where postoperative cross-sectional area was smaller than preoperative. Hematoma volumes were calculated. Multivariate analysis identified risk factors associated with postoperative hematoma volume. RESULTS After decompression, 58% of patients developed epidural hematoma of sufficient magnitude to compress the thecal sac beyond its preoperative state at one or more levels. None developed new postoperative neurologic deficits. A mean of 1.4 levels were decompressed. Hematoma extended over a mean of 1.9 levels. Maximal thecal sac compression due to hematoma occurred at an adjacent, nondecompressed level in 28% of patients. Multivariate analysis found age greater than 60, multilevel procedures, and preoperative international normalized ratio to be associated with larger hematoma volumes. CONCLUSION Lumbar decompression surgery results in a 58% incidence of asymptomatic compressive postoperative epidural hematoma. Adjacent level compression by hematoma occurs in 28% of patients. Advanced age, multilevel procedures, and international normalized ratio are independently associated with postoperative hematoma volume.
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Yoshimoto H, Sato S, Nakagawa I, Hyakumachi T, Yanagibashi Y, Nitta F, Masuda T. Deep vein thrombosis due to migrated graft bone after posterior lumbosacral interbody fusion. J Neurosurg Spine 2007; 6:47-51. [PMID: 17233290 DOI: 10.3171/spi.2007.6.1.47] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
✓The authors report the case of an 83-year-old woman with refractory sciatica attributable to isthmic spondylolisthesis at L-5. Her symptoms were successfully improved after posterior lumbar interbody fusion (PLIF) at L5–S1; however, notable swelling in her left leg suddenly developed 2 days postoperatively. Anterior migration of a fragment of bone graft was demonstrated on computed tomography scanning, and there was obvious occlusion of the left common iliac vein (CIV) on magnetic resonance venography. Ultrasonography revealed a thrombus in the left CIV at the site of compression. To prevent a pulmonary embolism during manipulation of the affected vein, an inferior vena cava filter was placed just before excision of the migrated bone fragment. The swelling in the patient’s leg subsided quickly after the surgery, and she was treated with heparin and warfarin to prevent recurrent deep vein thrombosis (DVT). Six months after the second surgery, complete restoration of blood flow to the left CIV and no recurrence of DVT were demonstrated on magnetic resonance venography. Especially in elderly patients with degenerative disc disease, excessive curettage and impaction of disc materials during the PLIF procedure may cause migration of bone graft fragments. Surgeons should be aware of the possible vascular complications of PLIF.
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21
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Morse K, Weight M, Molinari R. Extensive postoperative epidural hematoma after full anticoagulation: case report and review of the literature. J Spinal Cord Med 2007; 30:282-7. [PMID: 17684896 PMCID: PMC2031966 DOI: 10.1080/10790268.2007.11753938] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation. METHODS Case report. FINDINGS After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma. RESULTS Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy. CONCLUSIONS Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
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Affiliation(s)
- Kenneth Morse
- University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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22
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Sokolowski MJ, Dolan M, Aminian A, Haak MH, Schafer MF. Delayed Epidural Hematoma After Spinal Surgery A Report of 4 Cases. ACTA ACUST UNITED AC 2006; 19:603-6. [PMID: 17146305 DOI: 10.1097/01.bsd.0000211242.44706.62] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Symptomatic postoperative epidural hematoma is a rare and potentially devastating complication of spinal surgery. The overwhelming majority of reported cases have occurred in the immediate postoperative period. A recent publication defined the clinical entity of delayed postoperative epidural spinal hematoma as neurologic deterioration due to an epidural hematoma occurring at least 3 days after the index procedure. Only 2 such cases have been reported in the lumbar spine to date. Four cases of delayed postoperative spinal epidural hematoma were identified over a 6-year period among the spine surgeons at a single large academic institution. Each case involved the lumbar spine. The details of each patient's initial surgery, presentation, and hospital course were then gathered from a retrospective chart review. The 4 patients presented are unusual in their delayed symptomatic presentations of postoperative spinal epidural hematoma. Despite the longer time to onset, however, our patients exhibited many of the characteristics common to cases that presented in the acute postoperative period. The spine surgeon must remain vigilant for the possibility of postoperative spinal epidural hematoma in at-risk patients, even weeks after the original surgical procedure.
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Affiliation(s)
- Mark J Sokolowski
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA.
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23
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Ikuta K, Tono O, Tanaka T, Arima J, Nakano S, Sasaki K, Oga M. Evaluation of postoperative spinal epidural hematoma after microendoscopic posterior decompression for lumbar spinal stenosis: a clinical and magnetic resonance imaging study. J Neurosurg Spine 2006; 5:404-9. [PMID: 17120889 DOI: 10.3171/spi.2006.5.5.404] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Object
The incidence of postoperative spinal epidural hematoma (SEH) is low, and to the best of the authors’ knowledge, no researchers have evaluated its actual incidence and clinical features. The purpose of this study was to investigate the clinical consequences of SEH after microendoscopic posterior decompression (MEPD) in patients with lumbar spinal stenosis.
Methods
Data obtained in 30 patients undergoing MEPD for lumbar spinal stenosis were reviewed. At 1 week after surgery, magnetic resonance (MR) imaging documented SEHs in 10 patients (33% [Group 1]) and no evidence of SEHs in 20 patients (67% [Group 2]). The authors compared MR imaging findings, postoperative morbidities, and clinical outcomes between the groups.
Three Group 1 patients had symptomatic SEHs. All symptoms were mild without associated neurological deterioration and spontaneously subsided within 3 weeks of surgery. Magnetic resonance imaging demonstrated spontaneous regression of the SEH in all patients at 3 months after surgery. In Group 1 patients, however, the authors observed less expansion of the dural sac after 1 year despite sufficient widening of the osseous spinal canal. Low-back pain within 1 week of surgery was moderate in Group 1 and mild in Group 2. Improvements at the final follow up were greater in Group 2 patients.
Conclusions
The incidence of postoperative SEHs may be greater than reported. Postoperative SEHs caused poor expansion of the dural sac despite its spontaneous regression. In addition, postoperative SEHs caused a delay in the patient’s recovery and led to a poor clinical improvement. The prevention of postoperative SEHs might be required to prevent not only neurological deterioration but also a delay in the patient’s recovery.
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Affiliation(s)
- Ko Ikuta
- Department of Orthopedic Surgery, Hiroshima Red Cross and Atomic-Bomb Survivors Hospital, Hiroshima, Japan.
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Neo M, Sakamoto T, Fujibayashi S, Nakamura T. Delayed postoperative spinal epidural hematoma causing tetraplegia. J Neurosurg Spine 2006; 5:251-3. [PMID: 16961087 DOI: 10.3171/spi.2006.5.3.251] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓The authors describe a case of postoperative spinal epidural hematoma (PSEH) that developed in a patient 9 days after he underwent laminoplasty. A PSEH is a rare but critical complication of spinal surgery that usually occurs within a few days of the procedure. The authors draw attention to the possibility of delayed PSEH and its triggering mechanism. In this case, a 59-year-old man with no history of bleeding disorder underwent cervical laminoplasty for mild myelopathy. On the 7th postoperative day computed tomography demonstrated no abnormal findings in the operative field. On the 9th postoperative day, while straining to defecate, the patient suddenly felt neck and shoulder pain, and tetraplegia rapidly developed. Magnetic resonance imaging demonstrated a huge epidural hematoma. The clot was evacuated during emergency revision surgery, during which the arterial bleeding from a split muscle wall was confirmed. The postoperative course after the revision surgery was uneventful and the patient had none of the previous symptoms 1 year later.
A PSEH causing paralysis can occur even more than a week after surgery. The possibility of a delayed-onset PSEH should be kept in mind, and prompt diagnosis should be made when a patient presents with paresis or paralysis after an operation. The authors recommend advising patients that for a while after surgery they avoid strenuous activity.
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Affiliation(s)
- Masashi Neo
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. ACTA ACUST UNITED AC 2005; 87:1248-52. [PMID: 16129751 DOI: 10.1302/0301-620x.87b9.16518] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.
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Affiliation(s)
- J N Awad
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, A672, Baltimore, Maryland 21224, USA
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26
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Barnes B, Alexander JT, Branch CL. Postoperative Level 1 anticoagulation therapy and spinal surgery: practical guidelines for management. Neurosurg Focus 2004; 17:E5. [PMID: 15633991 DOI: 10.3171/foc.2004.17.4.5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors conducted a review of the literature to establish reasonable practical guidelines for the management of complications in patients who have undergone recent spinal surgery and who require Level 1 anticoagulation therapy. METHODS A MEDLINE (PubMed) literature search was performed using the key words "postoperative anticoagulation," "spinal surgery," and "postoperative epidural hematoma," for articles published between 1990 and 2004. The search yielded 148 articles, which were then further screened for relevance and classified according to level-of-evidence guidelines established by the American Association of Neurological Surgeons/Congress of Neurological Surgeons joint committee for spinal cord injury. A total of 12 relevant articles were reviewed. There were no relevant articles meeting Class 1 standards of evidence, two met Class 2 evidence standards (one was a nonrandomized cohort study, the other was case-controlled), and the remaining 10 articles contained Class 3 evidence. CONCLUSIONS There are insufficient data to establish evidence-based guidelines for the use of Level 1 heparin or an equivalent anticoagulation protocol in patients who have recently undergone spinal surgery. Nevertheless, a search of the limited peer-reviewed literature on the subject indicates that there is an anecdotally high risk of complications in patients who have undergone spinal surgery and in whom a Level 1 or equivalent heparin protocol is administered. It therefore seems most prudent to arrange for placement of a vena cava filter in patients who have undergone spinal surgery and in whom a pulmonary embolus is found postoperatively. In patients who undergo spinal surgery and who require heparinization therapy for myocardial ischemia or infarction, the use of frequent neurological examinations in conjunction with anticoagulation therapy seems to be the only reasonable option.
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Affiliation(s)
- Bryan Barnes
- Department of Neurosurgery, Wake Forest University Health Sciences, Winston-Salem, North Carolina 27157-1029, USA.
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Brambilla S, Ruosi C, La Maida GA, Caserta S. Prevention of venous thromboembolism in spinal surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2004; 13:1-8. [PMID: 14610663 PMCID: PMC3468034 DOI: 10.1007/s00586-003-0538-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2002] [Revised: 01/14/2003] [Accepted: 01/20/2003] [Indexed: 10/26/2022]
Abstract
Deep vein thrombosis (DVT), and its most feared complication, pulmonary embolism (PE), still have a high incidence with high risk for patients' health. Proven prophylactic measures are available but are generally underused, and DVT is still considered the most common cause of preventable death among hospitalized patients. The rationale for prophylaxis of venous thromboembolism is based on the clinically silent nature of the disease, the relatively high prevalence among hospitalized patients and the potentially tragic consequences of a missed diagnosis. During the last 15-20 years, spine surgery has changed radically, developing into a well-defined area of specialist surgery, and some attention is now being given to DVT events in spine surgery. The incidence of DVT during spine surgery is not documented in the literature, because only case reports or retrospective studies are reported. It would therefore be very helpful to initiate a multicenter study in order to understand this problem better and to develop, if possible, some guidelines on prophylactic measures in spine surgery. In doing so, we need to consider each patient's pattern, any risk factors and every kind of surgical technique related to DVT, in order to improve the outcome of the patient and to reduce any medicolegal problems that could arise from a thrombotic complication or an epidural hematoma, with its high potential for irreversible consequences.
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Affiliation(s)
- S Brambilla
- Department of Spinal Surgery, Gaetano Pini Orthopaedic Institute, Milan, Italy.
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30
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Abstract
STUDY DESIGN A case-control retrospective analysis comparing patients who developed a postoperative spinal epidural hematoma with patients who did not develop this complication. OBJECTIVES To identify risk factors for the development of an epidural hematoma following spinal surgery. SUMMARY OF BACKGROUND DATA Neurologic deterioration following spinal surgery is a rare but devastating complication. Epidural hematomas should be suspected in the patient who demonstrates a new postoperative neurologic deficit. The risk factors that predispose a patient to a postoperative spinal epidural hematoma have not been identified. METHODS Patients who underwent spinal surgery at a single institution over a 10-year period were retrospectively reviewed. Twelve patients who demonstrated neurologic deterioration after surgery and required surgical decompression because of an epidural hematoma were identified. All cases involved lumber laminectomies. A total of 404 consecutive patients that underwent lumbar decompression and did not develop an epidural hematoma formed the control group. Factors postulated to increase the risk of postoperative spinal epidural hematoma were compared between the two groups using logistic regression. RESULTS Multilevel procedures (P = 0.037) and the presence of a preoperative coagulopathy (P < 0.001) were significant risk factors. Age, body mass index, perioperative durotomies, and postoperative drains were not statistically significant risk factors. CONCLUSIONS Patients who require multilevel lumbar procedures and/or have a preoperative coagulopathy are at a significantly higher risk for developing a postoperative epidural hematoma.
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Affiliation(s)
- J Kou
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
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31
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Ghaly RF. Recovery after high-dose methylprednisolone and delayed evacuation: a case of spinal epidural hematoma. J Neurosurg Anesthesiol 2001; 13:323-8. [PMID: 11733665 DOI: 10.1097/00008506-200110000-00008] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Spinal epidural hematoma (SEH) is rare and not without serious sequelae. We report a patient who developed Brown-Séquard syndrome from SEH after fluoroscopic-guided cervical steroid injection and favorable response to methylprednisolone (MP). A 56-year-old man reported immediate sharp shooting pain to the upper extremities on introduction of epidural toughy needle. A total of 5 mL of 0.2% ropivacaine and 120 mg methylprednisolone acetate suspension was administered at the C6-7 interspace. Within half an hour, a neurologic deficit occurred at C7-8 and right Brown-Séquard syndrome developed. Once SEH was suspected (3 hours after onset of neurologic deficit), a protocol of high-dose MP intravenous infusion was initiated. Immediate incomplete recovery of motor, sensory, and sphincteric functions was noted within 30 minutes of infusion. Emergency spinal C6-T2 bilateral decompressive laminectomies and evacuation SEH were performed within an expected delay (10 hours from the onset of neurologic deficit). Fluoroscopic guidance does not take the place of adherence to meticulous technique. An unexplained neurologic deficit after invasive spinal procedures should raise the concern for SEH. Early recognition and emergent evacuation remain the mainstay management for SEH. This case suggests some neuroprotection from MP in cases of cervicothoracic cord compression secondary to traumatic SEH. When potential risks for SEH exist, it is advisable not to administer local anesthetic so as not to interfere with neurologic assessment and delaying the diagnosis.
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Affiliation(s)
- R F Ghaly
- Chicago Institute of Neurosurgery and Neuroresearch and Department of Anesthesiology and Pain Management, Cook County Hospital, Chicago, Illinois 60614, USA.
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