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BMJ Case Rep. 2010; 2010: bcr1020081089.
Published online 2010 December 2. doi:  10.1136/bcr.10.2008.1089
PMCID: PMC3030008
Other full case

Transient paraparesis as a consequence of spontaneous spinal epidural haematoma

Abstract

A 78-year-old man presented to the accident and emergency department following sudden onset of back pain, with attendant loss of power and sensation in the lower half of his body and urinary retention. Onset occurred while he was seated in a chair and he fell as he tried to get up. Neurological examination revealed symmetrical lower motor weakness (MRC grade 4/5) in both lower limbs with downgoing plantar reflexes. There was a clear sensory boundary at D4 with loss of joint position and sensation to light touch below this level. Rectal examination was unremarkable. While a CT head scan was normal, spinal MRI showed multilevel disc desiccations in the dorsal and lumbar spine. Additionally, in the dorsal spine at D4/5, there was a thin plaque of epidural tissue representing an epidural haematoma. Within 48–72 h the patient gradually and spontaneously regained full power.

Background

Transient paraparesis is a well-recognised clinical entity and does not always require surgical intervention. Previous reports of transient paraparesis have cited anterior circulation deficits,1 clopidogrel2 and other anticoagulants,3 and local spinal causes such as myelopathy, all of which necessitated surgical intervention.4 Spontaneous resolution has been reported on a few occasions but generally took months to complete.5

Case presentation

A 78-year-old man presented to the accident and emergency department following sudden onset of back pain, with attendant loss of power and sensation in the lower half of his body and urinary retention. Onset occurred while he was seated in a chair and he fell as he tried to get up. There were no other symptoms. His past medical history included myocardial infarction, hypertension and hypercholestrolaemia. As a consequence, his medications included aspirin, ramipril and simvastatin.

Neurological examination revealed symmetrical lower motor weakness (MRC grade 5/5) in both lower limbs but plantar reflexes were down going. There was a clear sensory boundary at D4 with loss of joint position and sensation to light touch below this level. Rectal examination was unremarkable. The patient was catheterised.

Investigations

While a CT head scan was normal, spinal MRI showed multilevel disc desiccations in the dorsal and lumbar spine (figure 1). Additionally, in the dorsal spine at D4/5, there was a thin plaque of epidural tissue, most likely representing an epidural haematoma (figure 2). Although there was some kyphosis, diffuse disc bulging and ligamentum flavum thickening, only the epidural haematoma was thought to account for the paraparesis and compromise of the spinal cord.

Figure 1
MRI scan of the spine showing multilevel disc desiccations in the dorsal and lumbar regions.
Figure 2
MRI scan at D4/5 level showing a thin line of plaque of epidural tissue representing an epidural haematoma.

Outcome and follow-up

Within 48–72 h the patient gradually and spontaneously regained full power. A trial without catheter was successful and he was discharged home for outpatient follow-up.

Discussion

This case supports the evidence that spontaneous spinal epidural haematoma can present with back pain and other symptoms of acute cord compression, including urinary retention.6 Resolution of these symptoms can occur within hours but may take days.

Learning points

  • [triangle] Transient paraparesis is a well-recognised clinical entity and does not always require surgical intervention.
  • [triangle] Recovery is usually protracted but this instance illustrates complete and spontaneous recovery may occur within 48 h.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Endo H, Shimizu H, Tominaga T. Paraparesis associated with ruptured anterior cerebral artery territory aneurysms. Surg Neurol 2005;64:135–9; discussion 139 [PubMed]
2. Karabatsou K, Sinha A, Das K, et al. Non-traumatic spinal epidural hematoma associated with clopidogrel. Zentralbl Neurochir 2006;67:210–12 [PubMed]
3. Tailor J, Dunn IF, Smith E. Conservative treatment of spontaneous spinal epidural hematoma associated with oral anticoagulant therapy in a child. Childs Nerv Syst 2006;22:1643–5 [PubMed]
4. Acebes JJ, Cabiol J, Gabarros A. Spinal epidural hematomas. Prognostic factors in a series of 22 cases and a proposal for management. Neurocirugia (Astur) 2004;15:353–9 [PubMed]
5. Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases. Spine 2001;26:E525–7 [PubMed]
6. Sakakibara R, Yamazaki M, Mannouji C, et al. Urinary retention without tetraparesis as a sequel to spontaneous spinal epidural hematoma. Intern Med 2008;47:655–7 [PubMed]

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