Spinal subdural hematoma mimicking epidural lipomatosis

Recurrent spinal subdural hematoma in granulomatosis with polyangiitis

Nervous system involvement is uncommon in granulomatosis with polyangiitis (GPA), a systemic autoimmune disease with episodes of necrotizing vasculitis. It is usually due to the compressive effect of dural or epidural masses. Spinal hemorrhagic presentation is exceptional. A 41-year-old woman diagnosed with GPA presented with three episodes of acute spinal subdural hematoma separated by eight years and ten months, respectively. The symptomatic debut was pain and paresis in all episodes. On all occasions, a lesion compatible with acute spinal subdural hematoma was diagnosed by magnetic resonance imaging (MRI). All episodes were treated conservatively with corticosteroids and immunosuppressants. The patient presented complete neurological recovery in the first two episodes. A mild residual left lower limb paresis remains after the last one. Follow-up MRI was performed after all episodes, and no focal intraspinal lesions were detected. Spinal subdural hemorrhage is a form of manifestation of GPA, either as a debut or in the course of the disease. We describe the third confirmed case of spontaneous spinal hemorrhage secondary to GPA published in the literature and the first with recurrence. Given the extraordinary response to immunosuppressive therapy, a high level of clinical suspicion is necessary to establish treatment as early as possible.

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.

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.

Patient-reported outcome of surgical treatment for lumbar spinal epidural lipomatosis

BACKGROUND CONTEXT

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of fat tissue in the spinal canal that can have a compressive effect, leading to clinical symptoms. This condition has a distinct pathology from spinal stenosis associated with degeneration of the intervertebral discs, ligaments, and facet joints. Several different conservative and surgical treatment strategies have been proposed for SEL, but its treatment remains controversial. There is a lack of evidence documenting the success of surgical decompression in SEL, and no previous studies have reported the postoperative outcome from the patient's perspective.

PURPOSE

The aim of the present study was to evaluate patient-rated outcome after surgical decompression in SEL.

STUDY DESIGN

A retrospective analysis of prospectively collected data was carried out.

PATIENT SAMPLE

A total of 22 patients (19 males; age: 68.2±9.9 years) who had undergone spine surgery for SEL were identified from our local Spine Surgery Outcomes Database, which includes a total of 10,028 spine surgeries recorded between 2005 and 2012. Inclusion criteria were epidural lipomatosis confirmed by preoperative magnetic resonance imaging (MRI) scans and subsequent decompression surgery without spinal fusion.

OUTCOME MEASURES

The Core Outcome Measures Index (COMI) was used to assess patient-rated outcome. The COMI includes the domains pain (separate 0-10 scales for back and leg pain), back-specific function, symptom-specific well-being, general quality of life (QOL), work disability, and social disability.

METHODS

The questionnaires were completed preoperatively and at 3, 12, and 24 months postoperatively. Surgical data were retrieved from the patient charts and from our local Spine Surgery Outcomes Database, which we operate in connection with the International Spine Tango Registry. Differences between pre- and postoperative scores were analyzed using paired t tests and repeated measures analysis of variance.

RESULTS

At 3-months follow-up, the COMI score and scores for leg pain and back pain had improved significantly compared with their preoperative values (p<.005). The mean decrease in COMI score after 3 months was 2.6±2.4 (range: -1.3 to 6.5) points: from 7.5±1.7 (range: 3.5-10) to 4.9±2.5 (range: 0.5-9.6). A total of 11 patients (50%) had an improvement of the COMI of more than the minimal clinically important change (MCIC) score of 2.2 points. The mean decrease in leg pain after 3 months was 2.4±3.5 (-5 to 10) points. Overall, 17 patients (77.3%) reported a reduced leg pain, 12 (54.6%) of whom by at least the MCIC score of 2 points. The significant reductions from baseline in COMI and leg and back pain scores were retained up to 2 years postoperatively (p<.02). The general QOL item of the COMI improved significantly after surgery (p<.0001). Over 80% of the cohort rated their preoperative QOL as bad (n=13) or very bad (n=5), whereas 3 months after surgery, only 7 patients rated their QOL as bad, and one as very bad (36%).

CONCLUSIONS

The present study is the first to demonstrate that surgical decompression is associated with a statistically significant improvement in patient-rated outcome scores in patients with symptomatic SEL, with a clinically relevant change occurring in approximately half of them. Surgical decompression hence represents a reasonable treatment option for SEL, although the reason behind the less good response in some patients needs further investigation.