Subarachnoid hematoma following lumbar puncture causing compression of the cauda equina. Case report

Surgical treatment of progressive cauda equina compression caused by spontaneous spinal subdural hematoma: A case report

RATIONALE

Spontaneous spinal subdural hematoma (SSDH) without an underlying pathology is a very rare condition. The treatment protocol for SSDH is early diagnosis and treatment before irreversible damage to neural tissue. However, there is no agreement on the etiopathogenesis, as well as the need for surgery to treat spontaneous SSDH. Here, we report a rare case of spontaneous SSDH with progressive deterioration and symptoms of cauda equina syndrome after ineffective conservative treatment.

PATIENT'S CONCERN

A 38-year-old male patient presented with sudden lower back and bilateral leg pain.

DIAGNOSIS

A magnetic resonance imaging (MRI) scan on the third day after the onset of symptoms revealed a subdural hematoma from L1 to S1, presenting as hyperintensities on T1 weighted sequences and hypointensities to isointensities on T2 weighted sequences.

INTERVENTION

Laminectomy and subdural evacuation were performed immediately.

OUTCOMES

An abnormal ligamentum flavum was observed intraoperatively. A histological examination revealed extravasation of blood in the degenerated ligamentum flavum. Postoperatively, the lower limb pain improved immediately. At the 6-month follow-up, the pain and numbness of the lower limb disappeared, and the muscle strength of both legs recovered completely with normal gait.

LESSONS

Spontaneous SSDH with ligamentum flavum hematoma was caused by a sudden increase of intravenous pressure, resulting from a marked surge in the intra-abdominal or intrathoracic pressure. Consecutive MRI scans provided valuable information, leading to a diagnosis of spontaneous SSDH. The treatment protocol for spontaneous SSDH should be determined based on the location and stage of the hematoma, as well as the subject's neurological status.

Unexpected intrathecal haemorrhage following uncomplicated placement and removal of an epidural catheter

We report a case of intrathecal and epidural haemorrhage 2 weeks after uncomplicated placement and removal of an epidural catheter in a patient that was initially scheduled for surgical repair of an aortic dissection and aneurysm. Included in this case report is a literature review and discussion of similar entities, differential diagnoses, and high yield learning points.

Subdural Thoracolumbar Spine Hematoma after Spinal Anesthesia: A Rare Occurrence and Literature Review of Spinal Hematomas after Spinal Anesthesia

Spinal hematomas are a rare but serious complication of spinal epidural anesthesia and are typically seen in the epidural space; however, they have been documented in the subdural space. Spinal subdural hematomas likely exist within a traumatically induced space within the dural border cell layer, rather than an anatomical subdural space. Spinal subdural hematomas present a dangerous clinical situation as they have the potential to cause significant compression of neural elements and can be easily mistaken for spinal epidural hematomas. Ultrasound can be an effective modality to diagnose subdural hematoma when no epidural blood is visualized. We have reviewed the literature and present a full literature review and a case presentation of an 82-year-old male who developed a thoracolumbar spinal subdural hematoma after spinal epidural anesthesia. Anticoagulant therapy is an important predisposing risk factor for spinal epidural hematomas and likely also predispose to spinal subdural hematomas. It is important to consider spinal subdural hematomas in addition to spinal epidural hematomas in patients who develop weakness after spinal epidural anesthesia, especially in patients who have received anticoagulation.

Iatrogenic spinal hematoma as a complication of lumbar puncture: What is the risk and best management plan?

Background:

Lumbar puncture (LP) rarely results in complications such as spinal hematomas. However, it remains unclear if certain variables increase likelihood of these events, or if surgical intervention improves outcome.

Methods:

In addition to two clinical vignettes, we evaluated the post-1974 literature for cases of spinal hematoma and subsequent intervention. Based on our compilation of data, we evaluated outcome relative to numerous distinct variables.

Results:

Based on 35 LP-related spinal hematoma cases in the post-1974 literature and our encounters, we found 28.6% of patients presenting with preexisting coagulopathy had poor outcomes regardless of intervention, relative to 14.3% of patients without coagulopathy; a highly significant difference (P = 0.02). Once diagnosed, 21 patients were treated surgically and 14 nonsurgically. Of the 60% surgical patients, 57.1% had good outcomes, and 42.9% had poor outcomes within 12 months. Of 40% nonsurgical patients, 57.1% had good outcomes and 42.9% had poor outcomes. Results in these groups were not statistically different.

Conclusions:

We found a significant correlation between preexisting coagulopathy and poor neurological outcome irrespective of intervention. However, outcomes for these patients may be confounded by comorbidities including underlying conditions contributing to their coagulopathy. No significant correlation between type of surgical intervention and good outcome was found, possibly attributable to the paucity of details in existing case reports and the difficulty defining the degree of spinal cord compromise from a given lesion. Despite our findings, emergent neurosurgical intervention may be beneficial for the management of complications such as cauda equina syndrome secondary to intrathecal spinal hematoma.

Spinal cord changes after the evacuation of a spinal subdural haematoma

Spinal subdural haematoma is a rare entity. Only a few cases have been reported, mainly in patients with coagulopathies or bleeding diathesis, and also in patients undergoing anticoagulant therapy following surgery, trauma, or lumbar puncture. Symptoms of spinal cord compression produced by spinal subdural haematoma may progress rapidly causing complete and irreversible deficits. However, rapid diagnosis and surgical intervention can result in a good functional outcome for the patient. We report on a 41-year-old woman with a normal coagulation profile who developed a spinal subdural haematoma after a minor motor vehicle accident. Although initially asymptomatic, she developed a dense quadriparesis over a 36-h period. A magnetic resonance imaging study demonstrated a subdural mass compressing the spinal cord, and at surgery a spinal subdural haematoma was found. She was discharged to an inpatient rehabilitation facility. Follow-up at 1 year showed significant improvement in motor function, but absence of posterior column function. A follow-up magnetic resonance study demonstrated widening of the spinal cord, advanced myelomalacia and a large, central, multi-loculated syrinx.

Spinal Subdural Hematoma Following Intracranial Aneurysm Surgery-Four Case Reports-

Four patients presented with rare spinal subdural hematoma (SDH) occurring after intracranial aneurysm surgery and manifesting as postoperative back pain. Magnetic resonance imaging performed from 4 to 11 days after the operation showed acute or subacute thoracolumbar SDH. No patient had risk factors for bleeding at this site (e.g., lumbar puncture, coagulation abnormality). Overdrainage of the cerebrospinal fluid (CSF) was performed for brain retraction during the operation in all four cases. Computed tomography performed during the postoperative period showed a suspicious tentorial subdural hemorrhage in Case 1 and an interhemispheric subdural hemorrhage in Case 3. All four patients received conservative management and their lumbago improved. We hypothesize that CSF hypotension due to overdrainage of CSF and downward migration of intracranial SDH under the influence of gravity were involved in the formation of spinal SDH.

Spinal chronic subdural hematoma in association with anticoagulant therapy: a case report and literature review

STUDY DESIGN

A case of spinal chronic subdural hematoma (SCSDH) in association with anticoagulant therapy was treated surgically.

OBJECTIVE

To clarify the etiopathogenesis, clinical presentation, and surgical outcomes of SCSDH.

SUMMARY OF BACKGROUND DATA

Intracranial chronic subdural hematoma is a well-recognized complication of anticoagulant therapy. However, SCSDH is very rare and its etiopathogenesis is uncertain.

METHODS

A 72-year-old man with SCSDH who had received anticoagulant therapy for atrial fibrillation complained of bilateral lower extremity pain, cramps, and gait disturbance. The patient underwent an operation for evacuation of the hematoma.

RESULTS

Lower-extremity pain, cramps, and gait disturbance improved, and the patient was discharged 10 days after surgery.

CONCLUSION

SCSDH should be included in the differential diagnosis of progressive spinal cord and nerve root compression in patients receiving anticoagulant therapy. Prompt diagnosis and early surgical decompression lead to a good outcome.

Spontaneous chronic spinal subdural hematoma associated with spinal arachnoiditis and syringomyelia

Spontaneous chronic spinal subdural hematoma is rare. We describe a case of spontaneous chronic spinal subdural hematoma associated with arachnoiditis and syringomyelia in a 76-year old woman who presented with a 14-year history of progressive myelopathy. MRI scan revealed a thoraco-lumbar subdural cystic lesion and a thoracic syrinx. The patient underwent thoracic laminectomy and decompression of the lesion, which was a subdural hematoma. A myelotomy was performed to drain the syrinx. Pathological examination revealed features consistent with chronic subdural membrane. This report attempts to elucidate the pathogenesis of chronic spinal subdural hematoma. We discuss possible etiological factors in light of the current literature and pathogenesis of both spinal subdural hematoma and syrinx formation.

Subarachnoid hematoma, hydrocephalus, and aseptic meningitis resulting from a high cervical myelogram

Despite its reduced use since the advent of magnetic resonance imaging, the high cervical myelogram remains a common diagnostic test in the evaluation of patients whose symptoms suggest cervical stenosis. We report a case of subarachnoid hematoma, hydrocephalus, and aseptic meningitis after a high cervical myelogram. A 52-year-old woman presented with headache, slurred speech, worsened neck pain and stiffness, and diffuse extremity weakness leading to gait instability beginning several hours after a cervical myelogram. Computed tomography (CT) scan revealed a C1-C2 hematoma below the dura, blood in the fourth and lateral ventricles, and hydrocephalus. An external ventricular drain was placed, and cerebrospinal fluid profile was consistent with aseptic meningitis. A suboccipital craniectomy and C1-C2 laminectomies were performed, followed by a C1-C2 durotomy, which revealed a large subarachnoid blood clot in the region of the cisterna magna extending down to the upper aspect of C2, which was evacuated by incising the arachnoid. In the midline at C1, an active source of intramedullary arterial bleeding on the dorsal surface of the spinal cord was coagulated. Spinal subarachnoid hematoma is a rare complication of high cervical myelogram. The extension of blood into the ventricular system with associated hydrocephalus has never been previously reported after myelography. Thus, severe persistent pain after cervical myelography should be evaluated by CT scans of the brain and cervical spine.

Low back pain due to spinal chronic subdural hematoma mimicking intradural tumor in the lumbar area: a case report and literature review

Although magnetic resonance imaging has dramatically enhanced the ability to diagnose spinal mass lesions, some lesions remain difficult to diagnose. We report a spinal chronic subdural hematoma that comprised the cauda equina ventrally in the lumbar area in a 51-year-old man who was under anticoagulant therapy. Low back pain was the only symptom of the patient after sports activity. Surgical treatment was performed 2 months after the onset of symptoms. Intraoperative view showed chronic subdural hematoma with abnormal enlarged dural vascularization. The patient had no preoperative and postoperative neurologic deficit. Low back pain with sudden onset after minor trauma refractory to medical treatment must be investigated with magnetic resonance imaging in patients under anticoagulant therapy for spinal hematoma because of the possibility of spinal chronic subdural hematoma.

Spinal subarachnoid hematoma compressing the conus medullaris and associated with neurofibromatosis type 2

STUDY DESIGN

Report of a case of subarachnoid hematoma associated with neurofibromatosis type 2 (NF2) in a 10-year-old girl.

OBJECTIVE

To report a rare case of subarachnoid spontaneous hematoma associated with NF2, with no evidence of trauma.

SETTING

Gifu, Japan.

METHODS

The patient presented with severe leg pain. MRI revealed a subarachnoid hematoma at the level of L2 and a spinal cord tumor at the level of T6. The subarachnoid hematoma had low and high heterogeneous signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image, indicating the presence of extracellular methemoglobin. The tumor and hematoma were resected.

RESULTS

Pathological analysis demonstrated that the surgical specimen removed from the area of L2 was a hematoma and the specimen from T6 was a neurinoma. At follow-up 1 year after surgery, the girl remained neurologically asymptomatic.

CONCLUSIONS

This rare case of spinal subarachnoid hematoma was associated with NF2. MRI was useful in establishing the diagnosis.

Acute hemorrhagic complication of diagnostic lumbar puncture

OBJECTIVE

To present a case of an epidural hematoma after lumbar puncture in a pediatric patient without known risk factors for such a complication and to review the literature regarding this complication.

DESIGN

Case report, review of the literature, and discussion.

DATA SOURCES

A review of MEDLINE (1966-1998) for keywords "lumbar puncture" and "hemorrhage" or "hematoma" was conducted, and each bibliography was reviewed for other sources extending to 1911. Articles describing a case of spinal hematoma after a lumbar puncture for any procedure were included.

RESULTS

A 5-year-old boy underwent a lumbar puncture for evaluation of lethargy and fever, and subsequently developed marked back pain and severe pain on flexion of his legs. Magnetic resonance imaging revealed an epidural blood collection. The patient's symptoms resolved over the next few days in association with steroid administration. Multiple reports of epidural and subdural hematomas were found on literature review, most occurring in the setting of coagulation abnormalities. These reports involve lumbar puncture in anesthetic, interventional, and diagnostic settings.

CONCLUSION

Lumbar puncture is a frequently employed procedure. Known complications include epidural, subdural, and subarachnoid hemorrhage, usually in the setting of abnormal coagulation. The case presented is unusual in that the patient is a child and lacks any known risk factors for a hemorrhagic complication. Such a complication appears to be rare; only five of the 64 cases discovered in the literature review occurred following this diagnostic procedure in patients without known risk factors.

A survey of spinal and epidural techniques in adult cardiac surgery

OBJECTIVE

To determine if a significant number of anesthesiologists are performing spinal and epidural techniques in adults undergoing cardiac surgery and if any neurologic injuries have been associated with these techniques.

DESIGN

Anonymous survey of clinical practice.

SETTING

Data collected via mail from members of the Society of Cardiovascular Anesthesiologists.

PARTICIPANTS

Attending anesthesiologists.

INTERVENTIONS

Anesthesiologists completed an anonymous survey of their use of spinal and epidural techniques in adult patients undergoing cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Of 3974 anesthesiologists, 974 (24%) responded to the questionnaire; 892 are at institutions that perform cardiac surgery. Of the 892 responders, 68 (7.6%) reported they use spinal techniques, whereas 62 (7%) reported they use epidural techniques. Nine (1%) anesthesiologists reported they use both techniques. There were no reports of neurologic complications related to the use of spinal or epidural techniques performed by the anesthesiologists responding to the survey.

CONCLUSIONS

A significant number of anesthesiologists are performing spinal and epidural techniques in adult patients undergoing cardiac surgery. Prospective, controlled trials should be performed to evaluate the benefits and risks of spinal and epidural techniques in this population.

Nontraumatic acute spinal subdural hematoma

✓ Acute subdural spinal hematoma occurs rarely; however, when it does occur, it may have disastrous consequences. The authors assessed the outcome of surgery for this lesion in relation to causative factors and diagnostic imaging (computerized tomography [CT], CT myelography), as well as eventual preservation of the subarachnoid space.

The authors reviewed 106 cases of nontraumatic acute subdural spinal hematoma (101 published cases and five of their own) in terms of cause, diagnosis, treatment, and long-term outcome.

Fifty-one patients (49%) were men and 55 (51%) were women. In 70% of patients the spinal segment involved was in the lumbar or thoracolumbar spine. In 57 cases (54%) there was a defect in the hemostatic mechanism. Spinal puncture was performed in 50 patients (47%). Late surgical treatment was performed in 59 cases (56%): outcome was good in 25 cases (42%) (in 20 of these patients preoperative neurological evaluation had shown mild deficits or paraparesis, and three patients had presented with subarachnoid hemorrhage [SAH]). The outcome was poor in 34 cases (58%; 23 patients with paraplegia and 11 with SAH).

The formation of nontraumatic acute spinal subdural hematomas may result from coagulation abnormalities and iatrogenic causes such as spinal puncture. Their effect on the spinal cord and/or nerve roots may be limited to a mere compressive mechanism when the subarachnoid space is preserved and the hematoma is confined between the dura and the arachnoid. It seems likely that the theory regarding the opening of the dural compartment, verified at the cerebral level, is applicable to the spinal level too. Early surgical treatment is always indicated when the patient's neurological status progressively deteriorates. The best results can be obtained in patients who do not experience SAH.

In a few selected patients in whom neurological impairment is minimal, conservative treatment is possible.

Traumatic spinal subarachnoid hematoma: report of a case with MRI

BACKGROUND

Spinal subarachnoid hematoma (SAH) is uncommon following traumatic injury to the spine. There are few case reports of neurologic deficit secondary to traumatic spinal SAH.

CASE DESCRIPTION

This 6-year-old boy was injured in a vehicular accident from which he became paraplegic and presented to us 1 week later. Plain X rays were normal and a myelo-computed tomography (CT) scan demonstrated an irregular intradural lesion from D10-L2. The magnetic resonance imaging (MRI) revealed an SAH at D11-12 level, posterior to the cord, which was surgically evacuated. The patient did not improve neurologically.

CONCLUSION

Significant cord injury and neurologic deficit can occur without obvious abnormalities on plain X rays or CT scan. MRI is very useful in detecting these lesions and can help in their management.

Spontaneous spinal subarachnoid hematoma--case report

BACKGROUND

Spinal subarachnoid hemorrhage is unusual, and rarely results in spinal subarachnoid hematoma because the cerebrospinal fluid tends to dilute the blood and prevent the formation of clots. We describe a patient with spinal subarachnoid hematoma of unusual spontaneous origin.

CASE

A 66-year-old female presented with sudden onset of intense back pain with paraplegia. Magnetic resonance imaging demonstrated a mass lesion between T2 and T6, compressing the spinal cord anteriorly. Emergency osteoplastic laminotomy exposed a hematoma in the subarachnoid space from T2 to T6, but no source of the hemorrhage was found. The patient was able to walk by herself about 20 days after the operation.

CONCLUSION

The outcome is significantly influenced by the duration between onset and operation, preoperative neurologic status, and rapidity of symptom progression. Therefore, we emphasize the importance of early diagnosis, and rapid and complete operative removal of spinal subarachnoid hematoma in order to achieve the best outcome.

Safety of lumbar puncture in patients with hemophilia

STUDY OBJECTIVE

To determine the safety of lumbar puncture in patients with hemophilia who are pretreated with clotting factor.

DESIGN

Retrospective analysis of medical records between 1980 and 1990.

SETTING

Three hospitals, each serving as a regional hemophilia center.

PARTICIPANTS

Thirty-three patients with hemophilia A or B who received one or more lumbar puncture.

INTERVENTION

All patients received replacement of deficient factor before the lumbar puncture. Serious post-lumbar puncture complications were defined as motor or sensory deficits, incontinence, or documented intraspinal hemorrhage.

RESULTS

Thirty-three patients with hemophilia A or B received a total of 52 lumbar punctures during the study period. Thirty of 33 patients (91%) had severe baseline factor deficiency, two (6%) had moderate deficiency, and one (3%) had mild deficiency. There were no serious complications reported as a result of the lumbar puncture. The 95% confidence interval for the risk of a serious complication was 0% to 5.8%.

CONCLUSION

With adequate factor replacement, a lumbar puncture can be done safely in patients with hemophilia.

A spinal haematoma occurring in the subarachnoid as well as in the subdural space in a patient treated with anticoagulants

A 75-year-old man on anticoagulant therapy suddenly experienced an excruciating back pain and subsequently developed a paraplegia. At operation a subarachnoid and a subdural haematoma were found, extending between the levels of the vertebrae T3 and L2. This extremely rare combination of haematomas may have been caused either by rupture of a small vessel in the arachnoid membrane or by rupture of the arachnoid membrane itself, secondary to a massive haemorrhage in the subarachnoid space.

Intracranial haemorrhage and death after iohexol myelography

Images

Spinal subdural hematoma. A review

Fifty-eight cases of spinal subdural hematoma were obtained from a review of the literature. Of these, 50 that were reported in detail are analyzed. The data corroborate the opinion that early diagnosis and treatment result in a better prognosis.

Spinal subarachnoid hematoma after lumbar puncture causing reversible paraplegia in acute leukemia. Case report

✓ Subarachnoid hematoma after lumbar puncture is extremely rare, even in patients with thrombocytopenia or other bleeding disorders. The authors report the case of a patient with acute leukemia and thrombocytopenia who developed paraplegia due to a subarachnoid hematoma following lumbar puncture. He recovered after an emergency laminectomy. If a subarachnoid hematoma occurs in a thrombocytopenic patient, prompt surgical treatment, in addition to intensive platelet support, can reverse the severe neurological consequences.

Radicular vessels are the most probable source of needle-induced blood in lumbar puncture: significance for the thrombocytopenic cancer patient

Despite knowledge of the bleeding hazard to thrombocytopenic cancer patients undergoing lumbar puncture (LP), a retrospective analysis of physician behavior at one hospital revealed no consistent use of platelet transfusions in patients with less than 20,000 platelets/mm3 on the day of LP. A review of the literature and laboratory cerebrospinal fluid (CSF) data in two institutions, and the performance of an LP experiment revealed that: (1) Batson's epidural venous plexus is an unlikely source and spinal radicular vessels are the most probable source of needle-induced blood in lumbar puncture; (2) the frequency of encountering needle-induced blood at LP is high, 73% (3) the frequency of brushing a nerve root, with the associated risk of lacerating the radicular artery or vein on its surface with the bevel of the LP needle, is high and may be on the order of 26%; and (4) while the passage of an LP needle, obturator in place, through a blood filled vein may carry red cells into a red cell-free medium, this does not always occur. These new considerations argue for more consistent adherence to the already published recommendation of platelet transfusion immediately prior to LP in patients with low platelets. This issue is of particular relevance to the rapidly growing population of thrombocytopenic cancer patients with extended survival on multiple chemotherapeutic regimens requiring lumbar puncture.

Subdural hematoma of the spinal cord and widespread subarachnoid hemorrhage complicating anticoagulant therapy

A patient developed paraparesis and signs of meningeal irritation spontaneously while on anticoagulant therapy. At autopsy, a subdural hematoma of the thoracic cord and evidence of widespread subarachnoid hemorrhage were found. The possible mechanism for these combined hemorrhages is discussed.

Acute spinal cord compression by subarachnoid and subdural hematoma occurring in association with brachial plexus avulsion. Case report

The authors report a case of acute spinal cord compression caused by a subarachnoid and subdural hematoma. This occurred following traumatic brachial plexus avulsion. It is believed to be the first such case recorded.

Spinal cord lesions after diagnostic and therapeutic procedures

This paper is dealing with spinal cord lesions following diagnostic and therapeutic procedures according to the literature and some personal observations. It becomes quite clear what prices have to be payed using modern methods. There are not only surgical procedures involved. Spinal cord lesions following medical activities cannot be judged as malpractice in any case. Some of these accidents can be avoided by strong indications and sophisticated performance of any procedure.

Spinal hematoma compressing cauda equina

Epidural and subdural spinal hematomas are unusual complications of diagnostic lumbar punctures. A renal allograft recipient on anticoagulant therapy underwent lumbar puncture. Urinary retention and evidence of an S2, S3, and S4 neurologic deficit developed subsequently. A myelogram showed a defect of the posterior lumbosacral spinal canal. Urodynamic investigation demonstrated normal sympathetic innervation of the proximal urethra and impaired parasympathetic and pudendal innervation of the detrusor and external urethral sphincter, respectively.