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)}

Classification

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⁾.

Etiology

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)}.

Gunshot wounds to the spine

see Gunshot wounds to the spine

Spinal surgery

see Postoperative spinal epidural hematoma

Spontaneus

see Spontaneous spinal epidural hematoma.

Clinical

see Spontaneous spinal epidural hematoma clinical features

Diagnosis

MRI poor for studying blood early.

Differential diagnosis

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⁾.

Complications

Brown-Séquard syndrome.

Cauda equina syndrome.

Treatment

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.

Case reports

see Spinal epidural hematoma case reports.