Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures

Paraplegia Caused by a Large Spinal Epidural Hematoma 12 Days After Thoracic Decompression and Fusion

A 41-year-old man with a history of obesity, hypertension, and smoking suffered from numbness and weakness in both lower limbs. He was diagnosed with ossification of the posterior longitudinal ligament and ligamentum flavum in the cervical and thoracic spine by X-rays, CT, and MRI. The patient underwent laminectomies at T2 and T3 levels, along with posterior fusion from T1 to T4, to address an upper thoracic spine lesion causing sensory deficits up to T5 and gait disturbances. The surgeries were T2 and T3 laminectomies and posterior T1-T4 fusion. The intraoperative and postoperative courses were uneventful. However, on the twelfth postoperative day, the patient suddenly experienced severe back pain followed by complete paralysis of both lower extremities, accompanied by significant swelling at the surgical site. An urgent MRI revealed a large hematoma dorsal to the dura mater, extending from T1 to T4. Emergent evacuation of the hematoma was performed, and no active bleeding was observed. Over time, a gradual improvement in the strength of the lower limbs was observed. Follow-up at two years postoperatively indicated the patient could walk unassisted for up to 1 km, although he continued to experience nocturnal urinary incontinence and erectile dysfunction. This case highlights the importance of recognizing that postoperative spinal epidural hematoma can develop even more than 10 days after spinal surgery. Patient and staff education is crucial to ensure prompt recognition and intervention.

A Rare Case of a Spontaneous Thoracic Epidural Hematoma in a Young Male Weightlifter

Spontaneous spinal epidural hematoma (SSEH) is the accumulation of blood in the epidural space of the spinal cord. Acute SSEH is a rare phenomenon that presents with a wide variety of neurologic symptoms and most often is a surgical emergency. We present a previously healthy 34-year-old male with sudden onset progressive weakness and tingling in the right lower extremity that progressed to the left lower extremity while bench pressing weights, resulting in complete lower extremity paralysis. Magnetic resonance imaging (MRI) revealed a 3.0 cm extradural mass centered in the dorsal and left lateral canal. After a T1-T4 hemilaminectomy was performed which was followed by inpatient rehabilitation, the patient had a favorable outcome improving from The American Spinal Injury Association Impairment Scale (AIS) grade A, complete impairment, to AIS grade C, incomplete impairment on discharge. Initially, the patient had complete motor and sensory paralysis below the level of T4, and upon discharge, the patient was able to attain modified independence in activities of daily living, mobility, and transfer. Due to the lack of risk factors for SSEH in this patient, the etiology is most likely related to the Valsalva maneuver while weightlifting. Lesions in the thoracic region with rapid progression of neurologic symptoms are indicators of poor prognosis, so this case highlights the importance of prompt recognition and intervention for improved outcomes to prevent devastating neurologic defects.

A Quick and Comprehensive Guide to Differential Diagnosis of Neck and Back Pain: a Narrative Review

The list of diagnostic options when approaching a patient with axial pain is impressively complex. Many offer limited diagnostic workups, but we could not find a truly comprehensive diagnostic guide to assist in the diagnostic evaluation. In this short paper, we briefly described a long list of medical conditions, each of which can manifest as back or neck pain, and whose prevalence ranges from common to very rare. We then proposed an algorithm for classifying them into subgroups. Further referral to diagnostic tests and specialist consultations, after assignment to one of those subgroups, could save time and unnecessary tests. We believe that this review and the proposed diagnostic algorithm can be valuable for medical education and for use in the primary care setting for the diagnostic evaluation of any type of back or neck pain in all patient groups.

Acute Spinal Extradural Hematoma and Cord Compression: Case Report and a Literature Review

A 50-year-old Asian male presented to the emergency department with sudden onset of bilateral lower limb weakness preceded by lower back pain, which developed after lifting a moderately heavyweight. As the pain increased in intensity, the patient was transferred by ambulance to the emergency department, and en-route lost complete motor (0/5 power and absent reflexes) and sensory control over his lower limbs. The patient's medical history was significant for diabetes mellitus, hypertension, chronic kidney disease, and coronary artery disease with percutaneous coronary intervention in 2018 and 2019. He was taking dual antiplatelets (aspirin and clopidogrel) along with other medications. Magnetic resonance imaging (MRI) showed findings suggestive of acute and extensive extradural hematoma extending from the foramen magnum to the level of the fifth lumbar vertebra (L5), exerting severe mass effect on the cord with evidence of edema, most severe at the level from 7th to 10th dorsal vertebrae (D7-D10) vertebral level. The clinical features and the radiological findings confirmed the diagnosis of acute cauda equina syndrome.

This review is intended to promote awareness about a possible clinical correlation between the use of dual antiplatelet therapy as a risk factor of spinal hematomas and the cauda equina syndrome.

Radiologic Features and Clinical Course of Chronic Spinal Epidural Hematoma: Report of 4 Cases and Literature Review

BACKGROUND

Spinal epidural hematoma (SEH) is a potentially devastating problem that requires rapid diagnosis and surgical intervention. A chronic course is rarely seen following SEH, and the clinical characteristics are quite different from acute cases. The epidemiology, clinical history, and radiologic findings of chronic SEH (CSEH) are not well understood, although the detection rate has increased with the widespread use of magnetic resonance imaging. The purpose of this article was to report 4 cases of surgically confirmed CSEH and clarify the radiologic features and clinical scenarios by reviewing all published cases of CSEH.

CASE DESCRIPTION

All 4 patients presented with gradually worsening radicular pain in the lower extremities. Patients' mean age was 69.5 years (range, 55-85 years). Magnetic resonance imaging revealed an epidural mass in the lower lumbar spine that was heterogeneously enhanced after gadolinium administration. The rim of the mass was low intensity on T2*-weighted images. Local erosions of the adjacent cortical bone were seen with computed tomography in all cases. All patients' postoperative courses were satisfactory with complete disappearance of radicular symptoms.

CONCLUSIONS

CSEH is a rare disease, and it is difficult to diagnose preoperatively on the basis of diagnostic imaging. The incidence of a low-intensity rim on T2*-weighted images and bone erosions on computed tomography may help differentiate rare CSEH from other lumbar degenerative diseases and epidural space-occupying masses.