A 46-year-old man, employed as a bricklayer, presented with a chief complaint of progressive left lower limb radiculopathy (visual analog score, VAS; 6/10) of two months duration. The patient's past medical history was unremarkable, especially with no use of aspirin or anticoagulant drugs and no known comorbidities (hypertension, vascular problems, diabetes, or coagulopathy). On physical preoperative examination, he showed a mild hypoesthesia in the left L4 dermatome. There was no bladder or erectile dysfunctions, and motor examination was normal. Radiographs of the lumbar spine did not reveal any significant abnormalities. Computed tomography of the lumbar spine demonstrated a left L3-L4 paramedian disc herniation (). Lumbar resonance magnetic imaging was not performed.
Fig. 1 (A, B) Preoperative lumbar CT-scan (A: sagittal image, B: axial image at the L3-L4 level) done 12 days prior to admission demonstrating a herniated disc at the level of the L3-L4 segment, with compression of the dural sac and the left L4 root. (C-F) Eight-hour (more ...)
The patient underwent a L3-L4 conventional microdiscectomy associated with a left L4 foraminotomy using a left intermyolaminar approach combined with a left interlaminar window in the genupectoral position under general anaesthesia. There was minimal blood loss, and no cerebrospinal fluid (CSF) leak was noted during surgery. No drain was inserted. At 2 hours postsurgery, the patient noted a complete resolution of the left L4 radiculopathy (VAS 1/10). At 8 hours postoperative, the patient complained of sudden-onset, severe pain radiating to the L4 dermatome (VAS 8/10) accompanied by numbness on both L4 dermatomes. Motor deficits were not observed. There was no bladder/bowel dysfunction. The postoperative magnetic resonance imaging (MRI) demonstrated an epidural mass with an isointense signal on T1-weighted and a hypersignal on T2-weighted sequences; the mass extended from T11-L5, consistent with acute epidural haemorrhage and compression of the dural sac at the L3-L4 intervertebral disc level (). No signs of vascular malformations, including dural arteriovenous malformations, were shown on the MRI.
The patient underwent re-operation at 9 hours postsurgery. The patient was prepared for a laminectomy extending from T11 to L5 in a prone position under general anaesthesia. The surgical strategy began with a re-opening of the initial surgical site to allow a faster evacuation of the SEH. A limited L4 left hemi-laminectomy was additionally performed, allowing the spontaneous expulsion of a mature blood clot. The dural sac expanded completely within the vertebral canal, and no CSF leak was noted. In addition, an epidural drain ascending to the upper lumbar levels for 5 cm was blindly introduced.
At 2 hours postsurgery, the patient presented a complete resolution of the bilateral L4 radiculopathy and numbness. Motor deficits and no bladder/bowel dysfunction were noted. The drain, opened under gravity, drained 100 ml of hematic fluid and was removed 24 hours postsurgery. The postoperative coagulopathy work-up showed no clotting disorder. No postoperative imaging was performed. The patient was discharged two days post-surgery. At two months, the neurologic examination was normal, MRI demonstrated no residual SEH, and the coagulopathy work-up was normal ().