Fatal spontaneous spinal subdural hematoma in a patient on anticoagulant therapy

Spinal subdural hematoma (SSDH) is characterized by sudden onset neck and/or back pain, dysuria, and extremity impairment. The use of anticoagulants is a significant risk factor for SSDH, indicating that early diagnosis is crucial. However, achieving a timely diagnosis can be difficult owing to the rarity of this condition. The first forensic autopsy of a patient who died as the result of a spinal subdural hematoma (SSDH) is presented. A woman in her 70s undergoing anticoagulant therapy was transported to the emergency room with headache, back pain, and lower limb paralysis. The patient was initially diagnosed with spondylolisthesis and subsequently went into cardiac arrest. Her autopsy revealed an SSDH extending from the first thoracic vertebra to the cauda equina, with no associated tumors or vascular abnormalities. A retrospective examination of the patient's imaging and clinical history indicated missed opportunities for early diagnosis. The patient's cause of death was determined to be neurogenic shock due to progressive spontaneous SSDH. This case underscores the importance of early diagnosis and treatment of SSDH, particularly in patients undergoing anticoagulant therapy who are at an increased risk of spontaneous SSDH. Although some studies have suggested that conservative treatment may be effective for cases involving mild symptoms, surgical decompression is generally required for those with rapidly worsening symptoms. SSDH, therefore, should be considered in the differential diagnosis of patients presenting with back pain and neurological deficits, as delays in diagnosis and treatment can significantly affect patient outcomes.

Simultaneous occurrence of epidural, subdural, and subarachnoid hemorrhages in the spinal canal: a rare case report

Simultaneous spinal epidural, subdural, and subarachnoid hemorrhages are exceedingly rare, with no prior documented case of all three occurring simultaneously in the literature. We present the case of a 59-year-old woman who developed acute lower back pain and progressive weakness in her lower extremities. MRI revealed three distinct types of hemorrhages: an epidural hematoma extending from T12 to the lumbar spine, a subdural hematoma between T11 and S1, and a subarachnoid hemorrhage involving the cauda equina. Surgical decompression was performed, leading to significant clinical improvement. This case underscores the critical role of MRI in the diagnosis of complex spinal hematomas and highlights the importance of prompt surgical intervention to prevent further neurological deterioration. Our report contributes valuable insights into the management of multifaceted spinal hemorrhages, emphasizing the need for early recognition and treatment in such rare presentations.

Cauda equina malignant peripheral nerve sheath tumor presenting with subarachnoid hemorrhage: a case report

Malignant peripheral nerve sheath tumors (MPNST) are uncommon aggressive neoplasms, frequently associated with type I neurofibromatosis. This is the first case of intradural lumbar spine MPNST with intraoperative findings of associated subarachnoid hemorrhage (SAH). A 72-year-old man presented to the emergency department with severe acute low back pain. Neurological examination was unremarkable. Gadolinium-enhanced MRI of the lumbar spine showed an irregularly shaped intradural lesion extending from L3 to L5. The lesion exhibited a medium signal both on T1 and T2-weighted imaging with peripheral enhancement. Through an L3-L5 laminectomy, a diffuse SAH, and a tumor tightly adherent to cauda equina nerve roots were found. Specimen examination revealed a fusocelular tumor with pleomorphic and hyperchromatic nuclei, positive for S100, and SOX10. On an 8-month follow-up, he had no neurological deficit, with a Karnofsky performance score of 90 points. Surgical evidence of SAH in lumbar spine intradural MPNST is a novel finding.

Imaging of the postoperative spine

There has been a significant increase in the number of spinal surgical procedures performed over the last few decades, resulting in a proportionate increase in the number of postoperative imaging studies.An exhaustive literature search was performed along with consideration of various guidelines and expert opinions regarding postoperative spine imaging. Complications are divided into early (in the first few weeks) and delayed, depending on the time of onset. Some complications occurring in the early postoperative period are common for both the instrumented and non-instrumented spine. Delayed complications are specific to the type of surgery performed and have been described as such. This review discusses the normal postoperative appearance and the various early and delayed complications.An understanding of the normal postoperative appearance is pertinent to distinguish normal from abnormal. A plain radiograph is the primary imaging modality for immediate postoperative assessment and long-term follow-up after spinal instrumentation. MRI with or without contrast is the imaging modality of choice for the evaluation of the postoperative spine. CT is the best modality for the assessment of the instrumented spine and status of bony fusion. Imaging assessment of the postoperative spine is complex and requires knowledge of key factors for interpretation like indications for the initial surgical procedure, type and approach of the surgical procedure, instrumentation used, time elapsed since surgery, and clinical complaints. · For proper interpretation of the postoperative spine, it is very important to understand the indication and type of spinal procedure involved. · Baseline postoperative radiographs are important to detect any change in the position of metalwork and implant integration.. · Computed tomography is the modality of choice to evaluate bony fusion and metalwork-specific complications. · Postoperative fluid collection is the most common early complication and MRI is the imaging modality of choice for the identification of the same.. · Intravenous gadolinium is helpful to differentiate between scar/vascularized granulation tissue and recurrent or residual disc.. · Kaur S, Lalam R, Trivedi R. Imaging of the postoperative spine. Rofo 2025; DOI 10.1055/a-2507-8347.

Dural Puncture Complications

Dural puncture, commonly referred to as lumbar puncture (LP), carries the risk of rare but serious complications including post-dural puncture headache, hemorrhage, herniation, and infection. These complications can lead to suboptimal patient outcomes including significant morbidity and mortality in some instances. This review comprehensively examines potential LP complications, including their incidence, pathophysiology, risk factors, clinical presentations, imaging findings, preventative measures, and treatment strategies. Familiarity with these complications will equip clinicians to effectively manage these complications through prompt recognition, timely diagnosis, and implementation of appropriate preventative measures.

Cysts and hematomas in the spine: Rare Entities

INTRODUCTION

Intervertebral discs are part of the vertebral column and are considered the pads that help in cushioning and flexibility. These discs consist of nucleus pulposus, annulus fibrosus, and cartilage end plate and their major functions include spinal motion and loading. However, they are prone to numerous pathologies such as intradiscal hematoma and discal cyst formation that may significantly alter the biomechanics of the spine and hence the quality of life of the patient. This case report aims to shed light on these rare pathologies.

CASE PRESENTATION

The following is a report on two cases demonstrating the difficulties in managing patients with intradiscal hematoma and discal cysts. Both cases are non-traumatic. The first case includes a 23-year-old male patient with right-sided lumbosacral pain unresponsive to conservative measures diagnosed with intradiscal hematoma using MRI. The second case concerns a 21-year-old male with left lumbar cruralgia following a motor vehicle accident. Conservative management at the onset helped to give a short time relief and when it relapsed it led to the diagnosis of an extradural compressive cyst that called for surgery.

DISCUSSION

An intradiscal hematoma provokes severe pain increasing with intraspinal pressure. Discal cysts, which are more frequent in young people, most likely manifest clinical signs of disc herniations. The pathophysiological theories may include the presence of hematomas or a gradual degenerative process due to mechanical stress. An MRI scan is essential for correct diagnosis and developing a proper treatment strategy for both diseases. The management of the condition includes medical treatment, physical therapy, injections, and surgical procedures for chronic cases.

CONCLUSION

The diagnosis and management of intervertebral disc pathology is quite challenging. The first case presents the deficiency of minimizing conservative approach in the management of intradiscal hematomas while the second case demonstrates the propensity for symptom reappearance in discal cysts and therefore the effectiveness of surgical management. MRI and other forms of imaging are vital in the diagnosis of the disease and in planning treatment. Science has embarked on the exploration of the exact causes of these diseases to enhance the lives of patients and the efficiency of the management of such illnesses.

Hemorrhagic encephalopathies and myelopathies in dogs and cats: a focus on classification

The prevalence of hemorrhagic diseases of the central nervous system of dogs and cats is low compared to other diseases such as neoplasia and inflammation. However, the clinical consequences can be devastating. Several etiological and localization-based classification systems have been reported for intracerebral and spinal cord hemorrhage or hematomyelia in humans but similar systems do not exist in veterinary medicine. The authors propose an etiologic classification system for both intraparenchymal hemorrhagic encephalopathy and myelopathy following a review of the literature detailing the presentation, diagnosis, therapy, and prognosis of these diseases. A summary of the investigative and therapeutic approach to these cases is also provided.

An unusual case of recurrent traumatic spinal epidural hematoma accompanied by osteoporotic vertebral compression fractures: Case report

RATIONALE

Traumatic spinal epidural hematoma (SEH) is a rare clinical condition. Here, we present an extraordinary case of recurrent SEH accompanied by thoracolumbar spine fractures resulting from minor trauma, and provide evidence-based recommendations for the surgical management strategies in this unique scenario.

PATIENT CONCERNS

A 71-year-old female patient presented with back pain after a fall. Magnetic resonance imaging revealed an SEH with L2 vertebral compression fracture. Following unsuccessful conservative treatment, percutaneous vertebroplasty was performed at the 2nd lumbar vertebra under local anesthesia. Two years later, the patient experienced another fall and was diagnosed with spinal hematoma with L1 vertebral compression fractures.

DIAGNOSES

The patient was diagnosed with recurrent osteoporotic vertebral compression fracture accompanying SEH.

OUTCOMES

After 1 week of conservative treatment, notable improvement of limbs numbness was observed. The patient ultimately underwent L1 vertebroplasty surgery. The patient was discharged smoothly on the third postoperative day and made a full recovery after 4 months.

LESSONS

SEH is a rare clinical finding that can occur even after a minor trauma in the elderly. It is worth noting that osteoporotic vertebral compression fractures with asymptomatic or stable intraspinal hematoma, is not considered to be a contraindication for percutaneous vertebroplasty. And percutaneous vertebroplasty is a safe and effective treatment for osteoporotic compression fractures with asymptomatic SEH.

Traumatic Spinal Subarachnoid Hemorrhage With Spinal Cord Compression: A Case Report and Literature Review

The occurrence of spinal hematoma is rare, and differentiation between subarachnoid hemorrhage and subdural hemorrhage on neuroradiological imaging can be challenging. Spinal subarachnoid hemorrhage (SSAH) is less frequently associated with trauma and can result in severe neurological impairment. We report the case of a 53-year-old man who presented with severe motor and sensory deficits primarily of the left arm without further neurological deficits in the other extremities after a fall from a height of six meters. Magnetic resonance imaging (MRI) showed an acute intradural hematoma at the C4-C6 level with significant spinal cord compression. Surgery revealed a hematoma enclosed by an arachnoid layer. Two months later, MRI showed complete resolution of spinal cord edema and avulsion of the left C6 and partially C7 nerve roots, corresponding to electromyography findings revealing a brachial plexus avulsion. Nine months after the accident and five months after surgical repair of the brachial plexus avulsion, there was a significant improvement in the sensory and motor functions of the left arm, allowing the patient to manage daily activities independently. Patients with neurological deficits following spinal trauma should be evaluated for spinal cord compression, such as intraspinal hematoma, as soon as possible to enable early spinal decompression. We describe a rare case of traumatic SSAH and brachial plexus avulsion following successful surgical decompression of the spinal cord without clinical postoperative myelopathy.

Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review

BACKGROUND

Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation.

METHODS

PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment.

RESULTS

We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%).

CONCLUSIONS

Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.

Spinal subdural haemorrhage secondary to strenuous exercise and warfarin, complicated by acute ischaemic stroke

Spinal subdural haemorrhage or haematoma (SSDH) is a rare condition that is often overlooked and missed on initial presentation due to its non-specific features that may mimic other more common pathologies. It is associated with high morbidity and mortality rates, with few evidence-based management principles, particularly during the subacute stages of recovery. In this report, we detail a case of SSDH associated with exercise and anticoagulation therapy, which was complicated by acute ischaemic stroke. SSDH should be suspected in cases of acute back pain without a clear alternative cause, particularly in coagulopathic individuals. Following treatment, early recommencement of anticoagulation therapy may be justified in certain cases where indicated, after careful consideration of the affected individual's risk profile.

Spontaneous epidural and subdural hematomas of the spine: Review of anatomy and imaging findings

Spontaneous epidural (SEH) and subdural hematomas (SSH) of the spine are a rare cause of spinal injury and morbidity. They often present in the emergency setting, though magnetic resonance imaging is the gold-standard for diagnosis. Knowledge of anatomy, and in particular of the dural layers of the spine, is crucial to understand the location of SEH and SSH and their relationship with spinal structure. In this pictorial review, we aim to explain imaging features of the SEH and SSH, and to rule out their main differential diagnosis.

Severe Mimic of Transverse Myelitis - Spontaneous Non-Traumatic Intramedullary Hematomyelia: A Case Report

Spinal cord hemorrhage remains an uncommon vascular pathology with no standard approach to treatment. Intramedullary hematomyelia is the rarest subtype and has only been described in case reports, making it a diagnosis easier to miss. A 55-year-old male with history of polysubstance abuse presented for abrupt onset non-traumatic back pain that progressed over several days evolving into paraplegia, sensory loss up to the T3 dermatome, and incontinence of bowel and bladder. His MRI imaging of the cervical and thoracic spine was concerning for a T1 and T2 hyperintense lesion extending from the internal medulla to the upper thoracic spine causing edema. The initial differential diagnosis, based on history and progressive neurologic decline, included a longitudinally extensive transverse mellitus of unclear etiology. He received high dose steroids and plasma exchange without any clinical improvement. An extensive autoimmune, inflammatory, infectious, and demyelinating workup via serum and CSF analysis was unremarkable. He was transferred to a tertiary facility, where repeat MRI spinal imaging included GRE sequences that was significant for increased susceptibility. MRA imaging of the spine was completed showing no vascular malformation. Overall, the diagnosis of hematomyelia was felt to be most likely. Despite aggressive inpatient rehabilitation, the patient remains paraplegic and requires long term management consistent with severe spinal cord injury. This case highlights the importance of recognizing vascular syndromes as a cause of acute myelopathy, understanding the imaging findings of blood breakdown products on MRI, and the desperate need for successful therapeutic strategies to combat a potentially devastating neurologic process.

Subdural spinal haematoma after epidural anaesthesia

Epidural anaesthesia is widely used in major thoracic and abdominal surgery for postoperative analgesia. Spinal haematoma after epidural anaesthesia in patients without risk factors is very rare. Most of the reported spinal haematomas arose in the epidural space, whereas the subdural localization seen in this case is very uncommon.We report a case of spinal subdural haematoma after difficult and repeated placement of an epidural catheter for postoperative analgesia. As no sensorimotor deficit of the lower limb arose, we refrained from immediate neurosurgical decompression and the patient recovered fully in the course. Nevertheless, any kind of spinal haematoma is a serious complication we should always be aware of. Prompt detection of clinical symptoms such as sensory or motor deficit is most important. Further diagnostic steps and treatment should not be delayed to avoid permanent neurological deficits.

Post-traumatic spinal hematoma in diffuse idiopathic skeletal hyperostosis (DISH)

OBJECTIVES

To determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH).

MATERIALS AND METHODS

A retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports.

RESULTS

Of 70 post-traumatic patients (54 men, median age 73, IQR 66-81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI.

CONCLUSIONS

SEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression.

CLINICAL RELEVANCE STATEMENT

Low-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation.

KEY POINTS

• Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH. • Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma. • Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.

Pain in the back after a brain trauma-The revelation of a spinal subdural hematoma: A case report with a literature review

Traumatic spinal subdural hematoma is a rare condition mostly favored by an anticoagulation therapy, a traumatic lumbar puncture, a hematologic disease, or an epidural anesthesia. This pathological condition can be subtle or be at the origin of a compression of the spinal cord and the rootlets resulting in an irreversible damage if an emergent surgery is not performed. We report the case of a 45-year-old man who has been a victim of a brain trauma which resulted in a cerebral edema. A week later, the patient came to the emergency department for disabling abdominal pain, predominant in the back. An abdominal computed tomography was performed and showed an incidentally spontaneous hyperdensity in the spinal cord, which raised the suspicion of a spinal hematoma that has been confirmed through spine magnetic resonance imaging. In this case, we discuss the different subtypes of spinal hematoma. We recall the main differential diagnoses to help setting an accurate diagnosis and to not delay the adequate therapy that is most of the time emergent when indicated.

Vascular Myelopathies

There are many vascular disorders that can affect the spinal cord, and their prevalence and etiology are highly influenced by age, sex, and risk factors. This article reviews the embryology and anatomy of the spinal cord, as well as several vascular conditions, describing their clinical and imaging presentation, emphasizing the different imaging modalities' contributions to increasing specificity and better defining the most appropriate therapy strategy for improving the patient's prognosis.

Early postoperative MRI findings following anterior cervical discectomy and fusion: What to expect when the unexpected happens

Background

Magnetic resonance imaging (MRI) is not routinely ordered following spinal fusion. Some literature suggests MRIs are unhelpful due to postoperative changes that obscure interpretation. We aim to describe findings of acute postoperative MRI following anterior cervical discectomy and fusion (ACDF).

Methods

The authors retrospectively analyzed adult MRIs completed within 30 days of ACDF (from 2005-2022). T1 and T2 signal intensity in the interbody space dorsal to the graft, mass effect on the dura/spinal cord, intrinsic spinal cord T2 signal, and interpretability were reviewed.

Results

In 38 patients there were 58 ACDF levels (1, 2, and 3 levels; 23, 10, and 5, respectively). MRIs were completed on mean postoperative day 8.37 (range; 0-30 days). T1-weighted imaging was described as isointense, hyperintense, heterogenous, and hypointense in 48 (82.8%), 5 (8.6%), 3 (5.2%), and 2 levels (3.4%), respectively. T2-weighted imaging was described as hyperintense, heterogenous, isointense, and hypointense in 41 (70.7%), 12 (20.7%), 3 (5.2%), and 2 levels (3.4%), respectively. There was no mass effect in 27 levels (46.6%), 14 (24.1%) had thecal sac compression, and 17 (29.3%) had cord compression.

Conclusions

The majority of MRIs exhibited readily compression and intrinsic spinal cord signal even with various types of fusion constructs. Early MRI after lumbar surgery can be difficult to interpret. However, our results support the use of early MRI to investigate neurological complaints following ACDF. Our findings do not support the idea that epidural blood products and mass effect on the cord are seen in most postoperative MRIs after ACDF.

Spinal Subdural Hematoma following Epidural Anesthesia

The spinal subdural space is an avascular, potential space and is a rare location for intraspinal hematomas. Compared to spinal epidural hematomas, spinal subdural hematomas are uncommonly described complications of lumbar puncture for spinal or epidural anesthesia, particularly in patients who have no pre-existing bleeding disorders or history of antiplatelet or anticoagulant intake. We describe a 19-year-old girl who had a large thoracolumbar spinal subdural hematoma following epidural anesthesia for elective cholecystectomy with no pre-existing bleeding diathesis that caused rapidly developing paraplegia that evolved over the next 2 days following surgery. Nine days after the initial surgery she underwent multilevel laminectomy and surgical evacuation with eventual satisfactory recovery. Even epidural anesthesia without thecal sac violation can result in bleeding in the spinal subdural space. The possible sources of bleed in this space may be from injury to an interdural vein or extravasation of subarachnoid bleed into the subdural space. When neurological deficits occur, prompt imaging is mandatory and early evacuation yields gratifying results.

Traumatic Spinal Epidural Hematoma With Significant Neurologic Findings: A Case Report

Traumatic spinal epidural hematoma (TSEH) is a rare neurosurgical emergency. Our case report centers around a young 34-year-old female brought into our emergency department after a front and rear motor vehicle collision. Clinical deterioration and imaging studies revealed a large spinal epidural hematoma extending from levels C5 to T2. The patient was subsequently transferred to a different hospital for further management. This case involved a multidisciplinary approach by the combined effort of emergency medicine physicians, neurosurgeons, orthopedic trauma surgeons, general surgeons, radiologists, intensive care specialists, anesthesiologists, paramedics and nurses.

Non-traumatic hemorrhagic myelopathy in dogs

BACKGROUND

Non-traumatic spinal cord hemorrhage (NTSH) is an uncommon cause of myelopathy in dogs.

OBJECTIVES

Describe the clinical characteristics, concurrent medical conditions and underlying causes, magnetic resonance imaging (MRI) findings and outcome in dogs with NTSH.

ANIMALS

Dogs diagnosed with NTSH using gradient echo T2-weighted (GRE) sequences with or without histopathological confirmation of hemorrhage were included. Dogs with a traumatic cause were excluded, including those with compressive intervertebral disc extrusion.

METHODS

Retrospective descriptive study; the databases of 2 referral hospitals were searched between 2013 and 2021.

RESULTS

Twenty-three dogs met inclusion criteria. The onset of signs was acute and progressive in 70% of cases; spinal hyperesthesia was variable (48%). Hemorrhage was identified in the thoracolumbar spinal segments in 65% of dogs. An underlying cause was identified in 65% of cases. Angiostrongylus vasorum represented 18% of the total cohort, followed by steroid-responsive meningitis arteritis (SRMA; 13%). Overall, 64% of dogs had a good or excellent outcome, regardless of cause; which was increased to 100% for SRMA, 75% for A. vasorum and 75% for idiopathic NTSH. Outcome was not associated with neurological severity. Recovery rate was 67% and 50% for nociception-intact and nociception-negative dogs, respectively.

CONCLUSIONS

Larger prospective studies would be required to define prognostic factors for dogs with NTSH, but outcome appeared to be most influenced by the underlying cause, as opposed to neurological severity at presentation.

Detection of Critical Spinal Epidural Lesions on CT Using Machine Learning

BACKGROUND

Critical spinal epidural pathologies can cause paralysis or death if untreated. Although magnetic resonance imaging is the preferred modality for visualizing these pathologies, computed tomography (CT) occurs far more commonly than magnetic resonance imaging in the clinical setting.

OBJECTIVE

A machine learning model was developed to screen for critical epidural lesions on CT images at a large-scale teleradiology practice. This model has utility for both worklist prioritization of emergent studies and identifying missed findings.

MATERIALS AND METHODS

There were 153 studies with epidural lesions available for training. These lesions were segmented and used to train a machine learning model. A test data set was also created using previously missed epidural lesions. The trained model was then integrated into a teleradiology workflow for 90 days. Studies were sent to secondary manual review if the model detected an epidural lesion but none was mentioned in the clinical report.

RESULTS

The model correctly identified 50.0% of epidural lesions in the test data set with 99.0% specificity. For prospective data, the model correctly prioritized 66.7% of the 18 epidural lesions diagnosed on the initial read with 98.9% specificity. There were 2.0 studies flagged for potential missed findings per day, and 17 missed epidural lesions were found during a 90-day time period. These results suggest almost half of critical spinal epidural lesions visible on CT imaging are being missed on initial diagnosis.

CONCLUSION

A machine learning model for identifying spinal epidural hematomas and abscesses on CT can be implemented in a clinical workflow.

Quantifying Intraparenchymal Hemorrhage after Traumatic Spinal Cord Injury: A Review of Methodology

Intraparenchymal hemorrhage (IPH) after a traumatic injury has been associated with poor neurological outcomes. Although IPH may result from the initial mechanical trauma, the blood and its breakdown products have potentially deleterious effects. Further, the degree of IPH has been correlated with injury severity and the extent of subsequent recovery. Therefore, accurate evaluation and quantification of IPH following traumatic spinal cord injury (SCI) is important to define treatments' effects on IPH progression and secondary neuronal injury. Imaging modalities, such as magnetic resonance imaging (MRI) and ultrasound (US), have been explored by researchers for the detection and quantification of IPH following SCI. Both quantitative and semiquantitative MRI and US measurements have been applied to objectively assess IPH following SCI, but the optimal methods for doing so are not well established. Studies in animal SCI models (rodent and porcine) have explored US and histological techniques in evaluating SCI and have demonstrated the potential to detect and quantify IPH. Newer techniques using machine learning algorithms (such as convolutional neural networks [CNN]) have also been studied to calculate IPH volume and have yielded promising results. Despite long-standing recognition of the potential pathological significance of IPH within the spinal cord, quantifying IPH with MRI or US is a relatively new area of research. Further studies are warranted to investigate their potential use. Here, we review the different and emerging quantitative MRI, US, and histological approaches used to detect and quantify IPH following SCI.

Hemophilia A Resulting in Severe Hyperesthesia Due to Extraparenchymal Spinal Cord Hemorrhage in a Young Golden Retriever Puppy

A ten-week-old male Golden retriever puppy was presented with severe hyperesthesia, mild neurological deficits and episcleral bleeding. Clotting times showed a normal prothrombin time (PT) and prolonged activated partial thromboplastin time (aPPT). Computed tomography (CT) of the vertebral column showed intradural, extraparenchymal hyperattenuating changes on precontrast CT images and epidural mass lesions, suggestive of hematorrhachis. Hemophilia A was confirmed by a low-factor VIII activity (FVIII:C). Although the dog improved clinically with intravenous analgesia and cage rest, it was euthanized by the owners’ choice because of the risk of developing future episodes of spontaneous hemorrhage. In young male puppies with severe hyperesthesia and mild neurological deficits, hemophilia A should be considered as a possible differential diagnosis.

Concurrent Spinal and Intracranial Subdural Hematomas as a Cause of Near-Fatal Low Back Pain in the Chiropractic Office: A Case Report

In older individuals, minor trauma may cause potentially fatal intracranial subdural hematoma (SDH). Rarely, these patients present with only low back and radicular pain as gravity redistributes the SDH to the lumbar spine. A 69-year-old male presented to a chiropractor with a 10-day history of acute on chronic low back pain, which radiated into his lower extremities bilaterally, involving weakness and difficulty walking, and a ground-level fall onto his elbows 16 days prior. He had visited his primary care provider, orthopedist, and traditional Chinese medicine practitioner, received oral analgesics and three ketorolac injections, and had lumbar radiographs, followed by acupuncture, cupping, and spinal manipulation without lasting relief. Considering the patient's concerning presentation, the chiropractor ordered lumbar magnetic resonance imaging (MRI) on the first visit, revealing findings suggestive of late subacute lumbar SDH, and recommended urgent brain MRI and neurosurgical referral. The patient went to an orthopedic surgeon at a nearby hospital, becoming disoriented upon presentation, prompting admission. Brain MRI confirmed bilateral chronic intracranial SDH, prompting emergency hematoma evacuation via burr hole craniostomy. The patient's gait rapidly improved, and the pain subsided over the following two weeks. This case highlights an older male identified as having spinal SDH by a chiropractor, leading to referral and surgery for concurrent life-threatening intracranial SDH. Clinicians should be aware that spinal SDH may stem from asymptomatic intracranial SDH and should be suspicious of SDH in older individuals after a fall, signs of which warrant emergency referral for MRI and surgical evaluation.

Symptomatic Postoperative Epidural Hematoma in the Lumbar Spine

A symptomatic postoperative epidural hematoma (SPEH) in the lumbar spine is a complication with variable presentation and the potential to rapidly cause an irrecoverable neurological injury. Significant heterogeneity exists among current case series reporting SPEH in the literature. This review attempts to clarify the known incidence, risk factors, and management pearls. Currently, literature does not support the efficacy of subfascial drains in reducing the incidence of SPEHs and possibly suggests that medication for thromboembolism prophylaxis may increase risk. Acute back pain and progressing lower extremity motor weakness are the most common presenting symptoms of SPEH. Magnetic resonance imaging is the mainstay of diagnostic imaging necessary to confirm the diagnosis, but if not acutely available, an immediate return to the operative theater for exploration without advanced imaging is justified. Treatment of a SPEH consists of emergent hematoma evacuation as a delay in repeat surgery has a deleterious effect on neurological recovery. Outcomes are poorly defined, though a significant portion of patients will have lasting neurological impairments even when appropriately recognized and managed.

Ventral Spinal Cord Herniation Causing Spinal Intradural Hematoma and Subarachnoid Hemorrhage: A Case Report

Ventral spinal cord herniation is a rare pathology, caused by a dural defect, that leads to progressive myelopathy. The true prevalence of ventral spinal cord herniation is unknown largely because of underdiagnosis due to its nonspecific symptoms. Though there are theories that attempt to describe how these dural defects are formed, the true causes of these defects are unknown. In this case report, we present a case of a 29-year-old female who had an idiopathic ventral spinal cord herniation causing an intradural hematoma and subarachnoid hemorrhage. This is the first reported case of spinal cord herniation causing hemorrhage.

Imaging of metastatic epidural spinal cord compression

Metastatic epidural spinal cord compression develops in 5-10% of patients with cancer and is becoming more common as advancement in cancer treatment prolongs survival in patients with cancer (1-3). It represents an oncological emergency as metastatic epidural compression in adjacent neural structures, including the spinal cord and cauda equina, and exiting nerve roots may result in irreversible neurological deficits, pain, and spinal instability. Although management of metastatic epidural spinal cord compression remains palliative, early diagnosis and intervention may improve outcomes by preserving neurological function, stabilizing the vertebral column, and achieving localized tumor and pain control. Imaging serves an essential role in early diagnosis of metastatic epidural spinal cord compression, evaluation of the degree of spinal cord compression and extent of tumor burden, and preoperative planning. This review focuses on imaging features and techniques for diagnosing metastatic epidural spinal cord compression, differential diagnosis, and management guidelines.

Imaging of intraspinal cystic lesions: A review

Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Postoperative spinal subdural hygroma without incidental durotomy: illustrative cases

BACKGROUND

Spinal subdural hygroma (SSH) is a rare pathological entity occurring as a complication of spinal surgery. It is different from spinal subdural hematoma due to blunt trauma, anticoagulation therapy, spinal puncture, and rupture of vascular malformations.

OBSERVATIONS

The authors presented five patients with SSH who received decompression for lumbar stenosis. None had incidental durotomy. All presented postoperatively with unexpectedly severe symptoms, including back and leg pain and weakness. Postoperative magnetic resonance imaging (MRI) revealed SSH with a characteristic imaging finding termed the “flying bat” sign. Four patients underwent evacuation of SSH, with immediate and complete resolution of symptoms in three patients and improvement in one patient. One patient improved without additional surgery. At surgery, subdural collections were found to be xanthochromic fluid in three patients and plain cerebrospinal fluid (CSF) in one patient.

LESSONS

Unexpectedly severe back and leg pain and weakness after lumbar or thoracic spine surgery should raise suspicion of SSH. MRI and/or computed tomography myelography shows the characteristic findings termed the flying bat sign. Surgical evacuation is successful although spontaneous resolution can also occur. The authors hypothesized that SSH is due to CSF entering the subdural space from the subarachnoid space via a one-way valve effect.

Ultrasound of congenital spine anomalies

Ultrasonography (US) is the first-line imaging modality for screening neonates and young infants with suspected spinal abnormalities. Whether performed for a suspicious congenital skin lesion, such as a lumbosacral tract or lipomatous mass, or abnormal neurological findings, US can help define spinal anatomy, characterize congenital spine malformations, and direct further work-up and management. The purpose of this article is to review the diagnostic imaging approach to infant spine US, including technique and indications, normal anatomy and variants with a focus on embryological origins, and classification and diagnosis of congenital spine malformations.

Spinal Subdural Haematoma: a rare complication of spinal decompression surgery

OBJECTIVE

Spinal Subdural Haematoma (SSH) is a rare and infrequently reported complication of hemilaminectomy, laminectomy and other spinal decompression surgeries. In this review, we aim to analyse the available literature for reported cases of SSH to better identify risk factors and presenting symptoms, as well as highlighting the importance in prompt investigation and management of SSH to prevent long-term morbidity and chronic neurological deficit.

METHOD

A review of the medical literature was undertaken using search terms hemilaminectomy OR laminectomy AND spinal subdural haematoma. All identified reports were screened for language, adult population and human studies. Report abstracts were screened for relevance to question, with SSH occurring postoperatively following hemilaminectomy or laminectomy included. Four reports were included in the review.

CONCLUSION

SSH is a rare, emergency condition with neurological deficit that can present as recurrent back pain and acute cauda equina post-operatively following hemilaminectomy and laminectomy procedures. Vigilance, early investigation and surgical evacuation is important in preventing short- and long-term morbidity. Further collation of data and analysis is required to better identify patients at high risk for developing SSH postoperatively.

Spine MRI: A Review of Commonly Encountered Emergent Conditions

Over the last 2 decades, the proliferation of magnetic resonance imaging (MRI) availability and continuous improvements in acquisition speeds have led to significantly increased MRI utilization across the health care system, and MRI studies are increasingly ordered in the emergent setting. Depending on the clinical presentation, MRI can yield vital diagnostic information not detectable with other imaging modalities. The aim of this text is to report on the up-to-date indications for MRI of the spine in the ED, and review the various MRI appearances of commonly encountered acute spine pathology, including traumatic injuries, acute non traumatic myelopathy, infection, neoplasia, degenerative disc disease, and postoperative complications. Imaging review will focus on the aspects of the disease process that are not readily resolved with other modalities.

ACR Appropriateness Criteria® Myelopathy: 2021 Update

Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Neuroimaging of Spinal Cord and Cauda Equina Disorders

PURPOSE OF REVIEW

This article reviews the neuroimaging of disorders of the spinal cord and cauda equina, with a focus on MRI. An anatomic approach is used; diseases of the extradural, intradural-extramedullary, and intramedullary (parenchymal) compartments are considered, and both neoplastic and non-neoplastic conditions are covered. Differentiating imaging features are highlighted.

RECENT FINDINGS

Although T2-hyperintense signal abnormality of the spinal cord can have myriad etiologies, neuroimaging can provide specific diagnoses or considerably narrow the differential diagnosis in many cases. Intradural-extramedullary lesions compressing the spinal cord have a limited differential diagnosis and are usually benign; meningiomas and schwannomas are most common. Extradural lesions can often be specifically diagnosed. Disk herniations are the most commonly encountered mass of the epidural space. Cervical spondylotic myelopathy can cause a characteristic pattern of enhancement, which may be mistaken for an intrinsic myelopathy. A do-not-miss diagnosis of the extradural compartment is idiopathic spinal cord herniation, the appearance of which can overlap with arachnoid cysts and webs. Regarding intrinsic causes of myelopathy, the lesions of multiple sclerosis are characteristically short segment but can be confluent when multiple. Postcontrast MRI can be particularly helpful, including when attempting to differentiate the long-segment myelopathy of neurosarcoidosis and aquaporin-4 (AQP4)-IgG-seropositive neuromyelitis optica spectrum disorder (NMOSD) and when characterizing spinal cord tumors such as primary neoplasms and metastases. Spinal dural arteriovenous fistula is another do-not-miss diagnosis, with characteristic MRI features both precontrast and postcontrast. Tract-specific white matter involvement can be a clue for diseases such as subacute combined degeneration, paraneoplastic myelopathy, and radiation myelitis, whereas gray matter-specific involvement can suggest conditions such as cord infarct, viral myelitis, or myelin oligodendrocyte glycoprotein (MOG)-IgG associated disorder.

SUMMARY

Knowledge of the neuroimaging findings of the many causes of spinal cord and cauda equina dysfunction is critical for both neurologists and neuroradiologists. A structured approach to lesion compartmental location and imaging feature characterization is recommended.

Post-traumatic spinal hematoma in ankylosing spondylitis

PURPOSE

The purpose of this study is to examine the incidence, location, and magnetic resonance imaging (MRI) features of spinal epidural hematoma (SEH) and spinal subdural hematoma (SSH) in post-traumatic ankylosing spondylitis (AS) patients.

METHODS

A total of 2256 consecutive referrals for urgent and emergency MRI scans of the spine over a period of eight years and nine months were manually reviewed for any mentions indicating axial ankylosis and post-traumatic spinal hematoma. We found 164 patients with ankylosed spines complicated by spinal fracture, of whom 32 had AS. Of the 132 excluded patients, 80 had diffuse idiopathic skeletal hyperostosis (DISH). The primary outcome was the presence of spinal hematoma, and the secondary outcome was spinal canal narrowing and spinal cord impingement. Two musculoskeletal radiologists and one fellow in musculoskeletal radiology reviewed the images for the presence of spinal hematoma and related signal characteristics, blinded to one another and initial reports.

RESULTS

Of 28 post-traumatic AS patients, 19 had SEHs and five had spinal SSHs. There was a statistically significant difference between Frankel grades before and after surgery in respect of neurological improvement (p = 0.008). Patients who had radiologically proven spinal cord impingement showed more severe neurological deficits (p = 0.012). Hematomas with T1 heterogeneity showed a significantly increased delay (p = 0.047) between injury and imaging, while other signal characteristics were only approximate.

CONCLUSIONS

Both SEH and SSH are common complications in post-traumatic AS patients. Patients benefit from surgery, but the relevance of spinal hematoma as a separate factor causing neurological deficit remains unclear.

Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists

The occurrence of acute myelopathy in a nontrauma setting constitutes a medical emergency for which spinal MRI is frequently ordered as the first step in the patient's workup. The emergency department radiologist should be familiar with the common differential diagnoses of acute myelopathy and be able to differentiate compressive from noncompressive causes. The degree of spinal cord compression and presence of an intramedullary T2-hyperintense signal suggestive of an acute cord edema are critical findings for subsequent urgent care such as surgical decompression. Importantly, a delay in diagnosis may lead to permanent disability. In the spinal canal, compressive myelopathy can be localized to the epidural, intradural extramedullary, or intramedullary anatomic spaces. Effacement of the epidural fat and the lesion's relation to the thecal sac help to distinguish an epidural lesion from an intradural lesion. Noncompressive myelopathy manifests as an intramedullary T2-hyperintense signal without an underlying mass and has a wide range of vascular, metabolic, inflammatory, infectious, and demyelinating causes with seemingly overlapping imaging appearances. The differential diagnosis can be refined by considering the location of the abnormal signal intensity within the cord, the longitudinal extent of the disease, and the clinical history and laboratory findings. Use of a compartmental spinal MRI approach in patients with suspected nontraumatic spinal cord injury helps to localize the abnormality to an epidural, intradural extramedullary, or intramedullary space, and when combined with clinical and laboratory findings, aids in refining the diagnosis and determining the appropriate surgical or nonsurgical management.Online supplemental material is available for this article.^©RSNA, 2019.

The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study

AIM

Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH.

MATERIAL AND METHODS

Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed.

RESULTS

The average degenerated soma intensity/mm³ at the C5-6 levels in the spinal cord was 2 ± 1/mm³, 13 ± 4/mm³, and 56 ± 10/mm³ for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm², 34 ± 9/mm², and 234 ± 78/mm² for Groups I, II, and III.

CONCLUSION

Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.

Acute Lumbar Spinal Subdural Hematoma Inducing Paraplegia After Lumbar Spinal Manipulation: Case Report and Literature Review

BACKGROUND

Traumatic spinal subdural hematoma is an extremely rare occurrence that requires urgent investigation and most often prompt intervention. To our knowledge, this is the first reported case related to a spinal manipulative therapy.

CASE DESCRIPTION

This report describes a case of traumatic lumbar subdural hematoma after a spinal manipulative therapy without any predisposing factor. A 23-year-old man was admitted to the emergency department for partial cauda equina syndrome after a spinal manipulation performed by a physiotherapist. Magnetic resonance imaging showed an acute spinal subdural hematoma at L2-L3 level with cauda equina compression. The patient underwent an emergency L2 laminectomy with evacuation of the hematoma. He recovered completely his neurologic functions after 1 week.

CONCLUSION

Practitioners of spinal manipulations should be aware of spinal subdural hematoma as a possible complication. A rapid diagnosis with magnetic resonance imaging is mandatory, and emergency surgical decompression is usually the optimal treatment for spinal subdural hematomas with severe neurologic deficit.

Spontaneous Spinal Subdural Hematoma: Case Report of 2 Years' Clinical and Radiologic Findings

BACKGROUND

Spontaneous spinal subdural hematoma (SDH) is rare but leads to severe nerve compression. According to the symptoms, surgery decompression and conservative treatment are justified options. We present a spontaneous spinal SDH case treated by decompression surgery for the lumbar region and conservative observation for the thoracic region. A series of images of the disease course is available.

CASE DESCRIPTION

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.

CONCLUSIONS

Surgical intervention is recommended in patients presenting with severe neurologic deficits. Conservative treatment is a reasonable option for asymptomatic patients.