Experience in the surgical management of spontaneous spinal epidural hematoma

Restricted access

Object. Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity. Although many cases have been reported in the literature, controversy persists as to its origin, diagnosis, and timing of treatment. The authors conducted a study in patients treated in their hospital and report the results.

Methods. Clinical data obtained in 35 patients with SSEH were retrospectively reviewed. Age, sex, history of hypertension, and history of anticoagulation therapy were recorded, and data were analyzed to clarify the possible predisposing factors of SSEH. Neurological outcomes were reappraised using a standardized grading system and correlated with the time interval from initial ictus to surgery, duration of complete neurological deficits, and the rapidity of deterioration of paralysis. Nonparametric methods and Spearman rank-correlation coefficients were used for statistical analysis.

Conclusions. Surgery is a safe and effective procedure to treat SSEH. The disease-related mortality rate was 5.7%, the surgery-related complication rate was 2.9%, and there were no operation-related deaths. Neurological outcome after surgery is positively correlated with preoperative neurological deficits (88.9% complete recovery in patients with incomplete neurological deficits compared with 37.5% in those with complete deficits [p < 0.001]). In patients in whom the time interval from initial ictus was shorter (< 48 hours) and in whom the duration of complete neurological symptoms was also briefer (< 12 hours), there is a positive correlation with better neurological and functional recovery (p < 0.05).

Article Information

Address reprint requests to: Shih-Tseng Lee, M.D., Department of Neurosurgery, Chang Gung Memorial Hospital, 5, Fu-shing Street, 333, Kweishan, Taoyuan, Taiwan. email: yun0710@adm.cgmh.org.tw.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Bar graph demonstrating distribution of age (in years) of 35 patients with SSEH.

  • View in gallery

    Bar graph showing distribution of involved segments of SSEH in 35 patients.

  • View in gallery

    Sagittal MR images obtained in a 2-year-old boy suffering from sudden-onset tonic head turning to the left and rapid sensorimotor paralysis (ASIA Grade A). A: A T1-weighted image of the cervicothoracic spine revealed an isointense C2—T4 fusiform intraspinal lesion. B: A T2-weighted image demonstrating that the lesion became primarily hyperintense to the spinal cord with foci of hypointensity. After complete neurological deficits persisted for 8 hours, the patient underwent laminectomy and evacuation of the intraspinal lesion, which was proven to be a fresh blood clot. Recovery was complete within 6 months. The SSEH had not recurred by the 3.5-year follow-up examination.

  • View in gallery

    Sagittal MR images obtained in a 6-month-old girl who experienced complete paraplegia 2 hours after an episode of upper—respiratory tract infection with fever and cough. She was treated for Guillain—Barré syndrome in a pediatric department for more than 1 week before cervical MR imaging was performed. The cervicothoracic images revealed a hyperintense C7—T7 fusiform lesion on both T1- (A) and T2-weighted (B) images with marked spinal cord compression. The intramedullary hyperintense signal on T2-weighted images represented spinal cord edema and possible infarction. Although she underwent evacuation of the lesion, she remained completely paraplegic with autonomic dysfunction 7.5 years after operation.

  • View in gallery

    Graphs showing the plots of median ASIA grades at 1, 3, 6, and 12 months postoperatively. Grades were converted into numerical equivalents (A, 1; B, 2; and so on). Death is indicated by a grade of 0. Upper: Outcome is significantly better in patients undergoing surgery within 48 hours after the initial symptom onset (Mann—Whitney U-test, p < 0.05). Lower: Better outcomes occurred in patients in whom the maximal duration of deficits was less than 12 hours (Mann—Whitney U-test, p < 0.05).

References

1.

Ainslie JP: Paraplegia due to spontaneous extradural or subdural hemorrhage. Br J Surg 45:5655671958Ainslie JP: Paraplegia due to spontaneous extradural or subdural hemorrhage. Br J Surg 45:565–567 1958

2.

Avrahami ETadmor RRam Zet al: MR demonstration of spontaneous acute epidural hematoma of thoracic spine. Neuroradiology 31:89921989Avrahami E Tadmor R Ram Z et al: MR demonstration of spontaneous acute epidural hematoma of thoracic spine. Neuroradiology 31:89–92 1989

3.

Beatty RMWinston KR: Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg 61:1431481984Beatty RM Winston KR: Spontaneous cervical epidural hematoma. A consideration of etiology. J Neurosurg 61:143–148 1984

4.

Boukobza MGuichard JPBoissonet Met al: Spinal epidural haematoma: report of 11 cases and review of the literature. Neuroradiology 36:4564591994Boukobza M Guichard JP Boissonet M et al: Spinal epidural haematoma: report of 11 cases and review of the literature. Neuroradiology 36:456–459 1994

5.

Bruyn GWBosma NJ: Spinal extradural hematoma in Vinken PJBruyn GW (eds): Handbook of Clinical Neurology.Amsterdam: North-Holland Publishing1976 pp 130Bruyn GW Bosma NJ: Spinal extradural hematoma in Vinken PJ Bruyn GW (eds): Handbook of Clinical Neurology. Amsterdam: North-Holland Publishing 1976 pp 1–30

6.

Carlier REngerand SLamer Set al: Foraminal epidural extra osseous cavernous hemangioma of the cervical spine: a case report. Spine 25:6296312000Carlier R Engerand S Lamer S et al: Foraminal epidural extra osseous cavernous hemangioma of the cervical spine: a case report. Spine 25:629–631 2000

7.

Chen CJHsu WC: Imaging findings of spontaneous spinal epidural hematoma. J Formos Med Assoc 96:2832871997Chen CJ Hsu WC: Imaging findings of spontaneous spinal epidural hematoma. J Formos Med Assoc 96:283–287 1997

8.

Cooper DW: Spontaneous spinal epidural hematoma. Case report. J Neurosurg 26:3433451967Cooper DW: Spontaneous spinal epidural hematoma. Case report. J Neurosurg 26:343–345 1967

9.

D'Angelo VBizzozero LTalamonti Get al: Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. Surg Neurol 34:3433441990D'Angelo V Bizzozero L Talamonti G et al: Value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation: case report. Surg Neurol 34:343–344 1990

10.

Dawson BH: Paraplegia due to spinal epidural hematoma. J Neurol Neurosurg Psychiatry 26:1711731963Dawson BH: Paraplegia due to spinal epidural hematoma. J Neurol Neurosurg Psychiatry 26:171–173 1963

11.

Foo DRossier AB: Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas. Surg Neurol 15:3894011981Foo D Rossier AB: Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas. Surg Neurol 15:389–401 1981

12.

Fukui MBSwarnkar ASWilliams RL: Acute spontaneous spinal epidural hematomas. AJNR Am J Neuroradiol 20:136513721999Fukui MB Swarnkar AS Williams RL: Acute spontaneous spinal epidural hematomas. AJNR Am J Neuroradiol 20:1365–1372 1999

13.

Graziani NBouillot PFigarella-Bragner Det al: Cavernous angiomas and arteriovenous malformations of the spinal epidural space: report of 11 cases. Neurosurgery 35:8568641994Graziani N Bouillot P Figarella-Bragner D et al: Cavernous angiomas and arteriovenous malformations of the spinal epidural space: report of 11 cases. Neurosurgery 35:856–864 1994

14.

Groen RJPonssen H: The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci 98:1211381990Groen RJ Ponssen H: The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci 98:121–138 1990

15.

Groen RJvan Alphen HA: Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 39:4945091996Groen RJ van Alphen HA: Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 39:494–509 1996

16.

Gundry CRHeithoff KB: Epidural hematoma of the lumbar spine: 18 surgically confirmed cases. Radiology 187:4274311993Gundry CR Heithoff KB: Epidural hematoma of the lumbar spine: 18 surgically confirmed cases. Radiology 187:427–431 1993

17.

Harik SIRaichle MEReis DJ: Spontaneous remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med 284:135513571971Harik SI Raichle ME Reis DJ: Spontaneous remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med 284:1355–1357 1971

18.

Hernandez DViñuela FFeasby TE: Recurrent paraplegia with total recovery from spontaneous spinal epidural hematoma. Ann Neurol 11:6236241982Hernandez D Viñuela F Feasby TE: Recurrent paraplegia with total recovery from spontaneous spinal epidural hematoma. Ann Neurol 11:623–624 1982

19.

Hillman JBynke O: Solitary extradural cavernous hemangiomas in the spinal canal. Report of five cases. Surg Neurol 36:19241991Hillman J Bynke O: Solitary extradural cavernous hemangiomas in the spinal canal. Report of five cases. Surg Neurol 36:19–24 1991

20.

Holtas SHeiling MLonntoft M: Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 199:4094131996Holtas S Heiling M Lonntoft M: Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 199:409–413 1996

21.

Joint National Committee on Prevention Detection Evaluation and Treatment of High Blood Pressure. National High Blood Pressure Education Program. Sixth report.Available at: http: //www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htmlJoint National Committee on Prevention Detection Evaluation and Treatment of High Blood Pressure. National High Blood Pressure Education Program. Sixth report. Available at: http: //www.nhlbi.nih.gov/guidelines/hypertension/jncintro.html

22.

Lawton MTPorter RWHeiserman JEet al: Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological coucome. J Neurosurg 83:171995Lawton MT Porter RW Heiserman JE et al: Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological coucome. J Neurosurg 83:1–7 1995

23.

Lee JPWang ADWai YYet al: Spinal extradural cavernous hemangioma. Surg Neurol 34:3453511990Lee JP Wang AD Wai YY et al: Spinal extradural cavernous hemangioma. Surg Neurol 34:345–351 1990

24.

Lonjon MMPaquis PChanalet Set al: Nontraumatic spinal epidural hematoma: report of four cases and review of the literature. Neurosurgery 41:4834871997Lonjon MM Paquis P Chanalet S et al: Nontraumatic spinal epidural hematoma: report of four cases and review of the literature. Neurosurgery 41:483–487 1997

25.

Lui TNLee ST: Chronic spontaneous spinal epidural hematoma. J Surg Assoc ROC 23:416201990Lui TN Lee ST: Chronic spontaneous spinal epidural hematoma. J Surg Assoc ROC 23:416–20 1990

26.

Markham JWLynge HNStahlman GE: The syndrome of spontaneous spinal epidural hematoma. Report of three cases. J Neurosurg 26:3343421967Markham JW Lynge HN Stahlman GE: The syndrome of spontaneous spinal epidural hematoma. Report of three cases. J Neurosurg 26:334–342 1967

27.

Mattle HSieb JPRohner Met al: Nontraumatic spinal epidural and subdural hematomas. Neurology 37:135113561987Mattle H Sieb JP Rohner M et al: Nontraumatic spinal epidural and subdural hematomas. Neurology 37:1351–1356 1987

28.

Maynard FM JrBracken MBCreasey Get al: International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Cord Injury Association. Spinal Cord 35:2662741997Maynard FM Jr Bracken MB Creasey G et al: International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Cord Injury Association. Spinal Cord 35:266–274 1997

29.

McQuarrie IG: Recovery from paraplegia caused by spontaneous spinal epidural hematoma. Neurology 28:2242281978McQuarrie IG: Recovery from paraplegia caused by spontaneous spinal epidural hematoma. Neurology 28:224–228 1978

30.

Olivero WCHanigan WCMcCluney KW: Angiographic demonstration of a spinal epidural arteriovenous malformation. Case report. J Neurosurg 79:1191201993Olivero WC Hanigan WC McCluney KW: Angiographic demonstration of a spinal epidural arteriovenous malformation. Case report. J Neurosurg 79:119–120 1993

31.

Pahapill PALownie SP: Conservative treatment of acute spontaneous spinal epidural hematoma. Can J Neurol Sci 25:1591631998Pahapill PA Lownie SP: Conservative treatment of acute spontaneous spinal epidural hematoma. Can J Neurol Sci 25:159–163 1998

32.

Pan WHChang HYYeh WTet al: Prevalence, awareness, treatment and control of hypertension in Taiwan: results of Nutrition and Health Survey in Taiwan (NAHSIT) 1993–1996. J Hum Hypertens 15:7937982001Pan WH Chang HY Yeh WT et al: Prevalence awareness treatment and control of hypertension in Taiwan: results of Nutrition and Health Survey in Taiwan (NAHSIT) 1993–1996. J Hum Hypertens 15:793–798 2001

33.

Pear BL: Spinal epidural hematoma. Am J Roentgenol Radium Ther Nucl Med 115:1551641972Pear BL: Spinal epidural hematoma. Am J Roentgenol Radium Ther Nucl Med 115:155–164 1972

34.

Post MJSeminer DSQuencer RM: CT diagnosis of spinal epidural hematoma. AJNR Am J Neuroradiol 3:1901921982Post MJ Seminer DS Quencer RM: CT diagnosis of spinal epidural hematoma. AJNR Am J Neuroradiol 3:190–192 1982

35.

Rohde VKüker WReinges MHet al: Microsurgical treatment of spontaneous and non-spontaneous spinal epidural hematomas: neurological outcome in relation to aetiology. Acta Neurochir 142:7877932000Rohde V Küker W Reinges MH et al: Microsurgical treatment of spontaneous and non-spontaneous spinal epidural hematomas: neurological outcome in relation to aetiology. Acta Neurochir 142:787–793 2000

36.

Rosenblum BOldfield EHDoppman JLet al: Spinal arteriovenous malformation: a comparison of dural arteriovenous fistulas and intradural AVM's in 81 patients. J Neurosurg 67:7958021987Rosenblum B Oldfield EH Doppman JL et al: Spinal arteriovenous malformation: a comparison of dural arteriovenous fistulas and intradural AVM's in 81 patients. J Neurosurg 67:795–802 1987

37.

Saito SKatsube HKobayashi Y: Spinal epidural hematoma with spontaneous recovery demonstrated by magnetic resonance imaging. Spine 19:4834861994Saito S Katsube H Kobayashi Y: Spinal epidural hematoma with spontaneous recovery demonstrated by magnetic resonance imaging. Spine 19:483–486 1994

38.

Tarlov IMHerz E: Spinal cord compression studies. IV. Outlook with complete paralysis in man. Arch Neurol Psychiatry 72:43591954Tarlov IM Herz E: Spinal cord compression studies. IV. Outlook with complete paralysis in man. Arch Neurol Psychiatry 72:43–59 1954

39.

Tarlov IM: Spinal cord compression studies. III. Time limits for recovery after gradual compression in dogs. Arch Neurol Psychiatry 71:5885971954Tarlov IM: Spinal cord compression studies. III. Time limits for recovery after gradual compression in dogs. Arch Neurol Psychiatry 71:588–597 1954

40.

van Swieten JCKoudstaal PJVisser MCet al: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:6046071988van Swieten JC Koudstaal PJ Visser MC et al: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607 1988

41.

Wagner SForsting MHacke W: Spontaneous resolution of a large spinal epidural hematoma. Case report. Neurosurgery 38:8168181996Wagner S Forsting M Hacke W: Spontaneous resolution of a large spinal epidural hematoma. Case report. Neurosurgery 38:816–818 1996

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 81 81 24
Full Text Views 117 117 9
PDF Downloads 78 78 10
EPUB Downloads 0 0 0

PubMed

Google Scholar