Spinal epidural hematoma (SEH)

Spinal epidural hematoma is an uncommon entity that was first reported as long ago as the 17th century. Jackson is generally credited with the first report of a spontaneous case in 1869 1) 2).

Till 1988, over 200 reports appeared in the literature, and numerous etiologies have been described 3) 4) 5)

Acute spinal epidural hematoma

Chronic spinal epidural hematoma

Chronic SEHs are rarer than acute SEHs.

see Cervical spinal epidural hematoma.

Spontaneous spinal epidural hematoma

Traumatic spinal epidural hematoma

Delayed spinal epidural hematoma (SEH): most symptomatic SEH occur within 72 hours of surgery; however, longer delays have been reported 6).

May be caused by traumatic or nontraumatic conditions that include coagulopathy, vascular lesions and iatrogenic or idiopathic causes.

Yamao et al first reported a operative and histological observation of recurrent spontaneous spinal epidural hematoma caused by a posterior venous plexus 7).

Spinal EDH's are believed to originate from the rich venous plexus of the epidural space. The most common area involved is the thoracic spine, where the epidural space is most prominent. The location of this venous plexus perhaps explains the greater number of reported EDH's of the spine compared with subdural and subarachnoid hemorrhage. It has been postulated that local pooling within the valveless, thin-walled epidural veins in combination with sudden brief increases in intravenous pressure may be the cause of such bleeds 8) 9).

see Gunshot wounds to the spine

Spinal surgery

see Postoperative spinal epidural hematoma


see Spontaneous spinal epidural hematoma.

see Spontaneous spinal epidural hematoma clinical features

MRI poor for studying blood early.

In the presence of an epidural mass with clear clinical symptomatology, rare entities like chronic epidural hematoma or posterior migrated disk material should be always considered as a differential diagnosis in patients with suspicion of extradural chronic compressions. In these cases, only the intraoperatory and histopathological exams can provide a clear diagnosis 10).

Brown-Séquard syndrome.

Cauda equina syndrome.

Recovery of the neurologic deficit without surgery is rare (only a handful of case reports in the literature 11), therefore optimal treatment is immediate decompressive laminectomy in those patients who can tolerate surgery 12). In one series, most patients who recovered underwent decompression within 72 hrs of the onset of symptoms. 13) In another, decompression within 6 hours was associated with a better outcome 14). High-risk patients: for medically high-risk patients (e.g. acute MI) on anticoagulation, surgical mortality, and morbidity is extremely high, and this must be considered when making the decision of whether or not to operate. In patients not operated on, anticoagulants should be stopped and reversed if possible. Consider the use of high-dose methylprednisolone to minimize cord injury

Percutaneous needle aspiration may be a consideration in high-risk patients.

see Spinal epidural hematoma case reports.

1) , 3) , 8)
Bruyn GW, Bosma NJ: Spinal extradural haematoma, in Vinken PJ, Bruyn GW (eds): Injuries of the Spine and Spinal Cord, Part II. Handbook of Clinical Neurology, Vol 26. Amsterdam: North-Holland, 1976, pp 1-30
Jackson R: Case of spinal apoplexy. Lancet 2:5-6, 1869
Wisoff HS: Spontaneous intraspinal hemorrhage, in Wilkins RH, Rengachary SS (eds): Neurosurgery. New York: McGraw-Hill, 1985, Vol 2, pp 1500-1504
Wittebol MC, van Veelen CWM: Spontaneous spinal epidural haematoma. Clin Neurol Neurosurg 86:265-270, 1984
Parthiban CJKB, Majeed SA. Delayed spinal extra- dural hematoma following thoracic spine surgery and resulting in paraplegia: a case report. 2008. http://www.jmedicalcasereports.com/content/2/1/141
Yamao Y, Takagi Y, Kawauchi T, Arakawa Y, Takayama M, Miyamoto S. Surgical Management of Recurrent Spontaneous Spinal Epidural Hematoma With 3 Episodes. Spine (Phila Pa 1976). 2015 Sep 1;40(17):E996-E998. PubMed PMID: 26323026.
Scott BB, Quisling RG, Miller CA, et ah Spinal epidural hematoma. JAMA 235:513-515, 1976
Iliescu BF, Chiriţă BC, Poeată I. The pitfalls of differential diagnosis of lumbar spine epidural lesions–exemplification with two particular cases and a review of the literature. Rev Med Chir Soc Med Nat Iasi. 2013 Oct-Dec;117(4):947-53. Review. PubMed PMID: 24502074.
Silber SH. Complete Nonsurgical Resolution of a Spontaneous Spinal Epidural Hematoma. Am J Emergency Med. 1996; 14:391–393
Harik SI, Raichle ME, Reis DJ. Spontaneous Remitting Spinal Epidural Hematoma in a Patient on Anticoagulants. N Engl J Med. 1971; 284:1355– 1357
Rebello MD, Dastur HM. Spinal Epidural Hemorrhage: A Review of Case Reports. Neurol India. 1966; 14:135–145
Porter RW, Detwiler PW, Lawton MT, et al. Postoperative Spinal Epidural Hematomas: Longitudinal Review of 12,000 Spinal Operations. BNI Quarterly. 2000; 16:10–17
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