Acute progressive neurological deficits may have a wide variety of causes. Painful paraparesis directs attention to a spinal location of pathology. Besides neoplastic and inflammatory lesions of the spine and spinal cord, SEH has to be taken into account even in patients without recent trauma and with normal blood coagulation and thrombocyte function10)
Cervical nerve-root blocks can be effective in both diagnosis and treatment of cervical radiculopathy1,4,5,11,12,14)
. But, complications of this procedure may cause severe neurologic deficits. Epidural hematoma, subdural complications such as respiratory depression and hypotension, postdural puncture headache, paresthesia, neuropathic pain, intracranial hypotension, epidural granuloma, cerebellar infarction, brain-stem herniation have been reported in the literature1,4-6,11,12)
In the case of our patient and in the case of the patient described by Stoll and Sanchez14)
, there was a delay in presentation of the paralytic symptoms following the last injections. This may be due to venous bleeding that slowly accumulated over several days12,14)
. In our case, the patients complained neurologic deteriorations two days after the final injection. Therefore, physicians should be aware and should inform their patients that potentially devastating neurological complications can occur days after an injection.
Spontaneous SEH is a rare but significant neurological condition2)
. Certain precipitating factors, including anti-coagulant therapy for prosthetic cardiac valves, therapeutic thrombolysis for acute myocardiac infarction, hemophilia B, factor XI deficiency, long-term aspirin using as a platelet aggregation inhibitor, and vascular malformation, are suggested to be correlated with spontaneous SEH2,8)
. Statistically, idiopathic cases account for approximatel 40% of all cases2)
. The most common site of a spontaneous SEH is the cervico-thoracic lesion. In our case, one patient who admited with paraplegia was spontaneous cervico-thoracic epidural hematoma.
The usual clinical presentation of a SEH is sudden severe neck or back pain that progresses toward paraparesis or quadriparesis, depending on the level of the lesion and the nerve root. In high cervical lesion, SEH could cause spinal shock, leading to fatal condition. In our cases, most patients were presented with motor weakness, sensory change, and gait disturbance ().
MR imaging can quite accurately characterize SEH and hence aid in early diagnosis and institution of definitive treatment13)
. Within 24 hour of onset, the SEH is usually iso-intense on T1-weighted images. Occasionally, there is a mildly or markedly increased signal. On T2-weighted images, there may be homogenous high signal or inhomogenous areas of mixed high and low signal. After 24 h, there is usually a high signal on T1-weighted images. T2-weighted images in most cases are the same signal as CSF. Important differential diagnosis to exclude are epidural hematoma, subdural hematoma, epidural metastasis and epidural abscess10,13)
Early surgical intervention is the general treatment for SEH1,2,4,5,8-14)
. Rapid diagnosis and emergent surgical treatment maximize the neurological recovery13)
. The procedure includes partial or total laminectomy and hematoma removal. If the exact location of the hematoma cannot be detected and confirmed by image, the dura is opened to exclude the subdural hematoma2)
. In cases with incomplete preoperative sensorimotor deficit, early surgery (within 36 h) are correlated with better outcome. Mortality is higher in patients with cervical or cervico-thoracic hematomas, especially in patients with cardiovascular disease and those on anti-coagulant therapy2,13)
There have been reported cases of spontaneous resolution of spinal epidural hematomas with good neurological recovery8,13)
. Some authors have proposed conservative management by lumbar puncture13)
. However, prompt surgical decompression should remain the treatment of choice except in cases whose operative risk is high and in cases with no neurological deficit1,2,4,5,8-14)