Spinal epidural hematoma without significant trauma in children: two case reports and review of the literature

Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation: A case report and review of literature

BACKGROUND

While most complications of cervical surgery are reversible, some, such as symptomatic postoperative spinal epidural hematoma (SEH), which generally occurs within 24 h, are associated with increased morbidity and mortality. Delayed neurological dysfunction is diagnosed in cases when symptoms present > 3 d postoperatively. Owing to its rarity, the risk factors for delayed neurological dysfunction are unclear. Consequently, this condition can result in irreversible neurological deficits and serious consequences. In this paper, we present a case of postoperative SEH that developed three days after hematoma evacuation.

CASE SUMMARY

A 68-year-old man with an American Spinal Injury Association (ASIA) grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall. The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day. Postoperatively, the patient showed no changes in muscle strength or ASIA grade. The patient experienced neck pain and subcutaneous swelling on the third day postoperatively, his muscle strength decreased, and his ASIA score was grade A. Magnetic resonance imaging showed hypointense signals on T1 weighted image (T1WI) and T2WI located behind the epidural space, with spinal cord compression. Emergency surgical intervention for the hematoma was performed 12 h after onset. Although hypoproteinemia and pleural effusion did not improve in the perioperative period, the patient recovered to ASIA grade C on day 30 after surgery, and was transferred to a functional rehabilitation exercise unit.

CONCLUSION

This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery. Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

Paralysis of the lower limbs caused by spontaneous spinal epidural hematoma: A case report

INTRODUCTION AND IMPORTANCE

Spontaneous spinal epidural hematoma (SSEH) is a rare surgical emergency, often with acute onset, causing severe spinal cord injury. This report presents a case of SSEH treated by surgery to enhance understanding of this disease.

CASE PRESENTATION

A 76-year-old male patient sought medical care for unexplained sudden chest and back pain and paralysis of both lower extremities. Magnetic resonance imaging (MRI) confirmed the occupation of thoracolumbar spinal canal. The blood clot was completely removed by emergency surgery, and then the neurological function recovered.

CLINICAL DISCUSSION

Spontaneous spinal epidural hematoma is an uncommon disease, its acute onset, resulting in difficult to recover spinal cord injury, or even permanent paralysis. Therefore, early diagnosis and early operation are the key to the protection of neurological function.

CONCLUSIONS

Surgical intervention is the first choice for treatment, especially in acute and subacute spontaneous spinal epidural hematoma. Once diagnosed, and there are no contraindications, it is recommended to remove and decompress the hematoma as soon as possible.

Neurological Complications Associated with Hereditary Bleeding Disorders

PURPOSE OF REVIEW

Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies.

RECENT FINDINGS

ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.

Delayed Diagnosis of Cervical Epidural Hematoma in a 3-Year-Old Boy: A Case Report

CASE

A 3-year-old boy presented to the emergency department with torticollis after a fall. With normal cervical radiographs and neurologic exam, he was diagnosed with cervical strain and discharged. After 2-week progressive symptoms, he was referred to a pediatric spine surgeon. Magnetic resonance imaging (MRI) revealed a cervical epidural hematoma, which was then surgically evacuated. He recovered fully and remains symptom-free 2 years later.

CONCLUSION

Pediatric spinal epidural hematoma is a rare condition with potentially serious outcomes yet often nonspecific symptoms. Timely management based on a comprehensive evaluation of symptoms and imaging findings is crucial in improving patient outcomes.

Insidious onset of spontaneous spinal epidural hematoma in immune thrombocytopenic purpura: a case-based review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) can result from various etiologies with a variable degree of neurological deficits. Here, we describe a rare case of SEH secondary to immune thrombocytopenic purpura (ITP) in a child and review the literature of SSEH caused by ITP.

CASE REPORT

A 9-year-old female who presented with rapid neurological decline, including bowel and bladder incontinence and paraparesis. A SSEH was observed extending from C2 to T6, causing a mass effect on the spinal cord. Her platelet count was only 7000/µL. Multidisciplinary care was established with neurosurgery, pediatric hematology, and pediatric surgery. The patient was managed emergently with splenectomy and surgical evacuation, with multilevel laminectomy and laminoplasty for evacuation of the hematoma. After a short course of rehabilitation, the patient regained all neurological function.

CONCLUSION

We report the first case of cervicothoracic SSEH secondary to ITP in a child managed with emergent splenectomy and surgical evacuation with multilevel lamoplasty. We also described the methods of timely diagnosis, urgent management, and overall prognosis of patients with this condition.

Spontaneous spinal epidural hematoma in a pediatric hemophiliac

Background

Spontaneous spinal epidural hematomas (SSEH), unrelated to trauma, epidural anesthesia, or surgery, are rare in the pediatric population. Here, a 1-year-old male with hemophilia presented with a magnetic resonance (MR)-documented SSEH and was successfully treated with a C5-T10 right hemilaminectomy.

Case Description

A 1-year-old male with hemophilia presented with quadriparesis. The holo-spine magnetic resonance imaging with contrast showed a posterior cervicothoracic compressive epidural lesion extending from C3 to L1 consistent with an epidural hematoma. He underwent a C5 to T10 right-sided hemilaminectomy for clot removal, following which his motor deficits fully resolved. A literature review of SSEH attributed to hemophilia revealed that 28 of 38 cases were effectively treated conservatively, while only 10 cases warranted surgical decompression.

Conclusion

Select patients with SSEH attributed to hemophilia with severe MR-documented cord/cauda equina compromise and significant accompanying neurological deficits may require emergent surgical decompression.

A Rare Case of Traumatic Cervical Spinal Epidural Hematoma in a Toddler: A Two-Year Follow-Up

Traumatic cervical epidural hematoma is a rare disease in the pediatric population. It requires a high level of suspicion in children who presents with acute neurological deficit after trauma. Magnetic resonance imaging (MRI) is required to confirm the diagnosis. Early surgical intervention is recommended to have the best neurological outcome. We report a case of a traumatic cervical epidural hematoma in a toddler with complete paraplegia, which partially recovered after decompressive surgery. We would like to emphasize the importance of high suspicion for this condition and the need for an urgent MRI to confirm the diagnosis.

Treatment of spontaneous spinal epidural hematoma in children: analysis of 25 cases

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare neurosurgical emergency, presenting as sudden onset of back pain and weakness of lower extremities. Many patients have no definite cause. Some cases of SSEH caused by vascular malformation have been reported. The treatment strategy remains controversial. This study aimed to analyze the causes of SSEH and proposed a treatment strategy according to clinical outcomes of patients at a single institution.

METHODS

A total of 25 cases of SSEH under 18 years of age treated between March 2004 and July 2021 were retrospectively analyzed.

RESULTS

The mean age of the first SSEH onset was 7.1 years. The most common location was cervicothorax. Nine patients suffered from multiple episodes. Twenty-three patients underwent spinal digital subtraction angiography (DSA), of which seven (30.4%) patients had positive findings: three cases had epidural artery venous fistula (AVF), two cases had epidural artery venous malformation (AVM), and two cases had abnormal concentration of contrast agent. Seventeen patients received surgery. Eleven patients (44%) were diagnosed as vascular malformation by either DSA or pathology. The follow-up rate was 80%, with 20 patients (80%) achieving satisfactory clinical outcome. Risk factors for poor clinical outcome included multiple episodes (p = 0.028) and higher Aminoff-Logue score (p = 0.005).

CONCLUSION

Spinal epidural vascular malformation is a significant cause of SSEH. Spinal DSA is necessary. Surgery should be recommended for patients with multiple episodes, positive findings on DSA, or severe neurological deficits. Conservation therapy can be considered for other patients, but long-time follow-up is necessary.