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1.  Postoperative spinal epidural hematoma resulting in cauda equina syndrome: a case report and review of the literature 
Cases Journal  2009;2:8584.
Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.
doi:10.4076/1757-1626-2-8584
PMCID: PMC2740261  PMID: 19830087
2.  Post-operative spinal epidural hematoma causing American Spinal Injury Association B spinal cord injury in patients with suction wound drains 
Background
Subfascial wound suction drains are commonly used after spinal surgery to decrease the incidence of post-operative hematoma. However, there is a paucity of literature regarding their effectiveness.
Objective
To report four cases of post-operative spinal epidural hematoma causing massive neurological deficit in patients who had subfascial suction wound drains.
Methods
During an 8-year period, a retrospective review of 1750 consecutive adult spinal surgery cases was performed to determine the incidence, commonalities, and outcomes of catastrophic neurological deficit caused by post-operative spinal epidural hematoma.
Findings
Epidural hematoma causing major neurological deficit (American Spinal Injury Association B) was identified in 4 out of 1750 patients (0.23%). All four patients in this series had subfascial wound suction drains placed prophylactically at the conclusion of their initial procedure.
Results
Three patients developed massive neurological deficits with the drain in place; one patient had the drain removed at 24 hours and subsequently developed neurological symptoms during the following post-operative day. Significant risk factors for the development of hematoma were identified in two of the four patients. Average time to return to the operating room for hematoma evacuation was 6 hours (range 3–12 hours). Neurological status significantly improved in all four patients after hematoma evacuation.
Conclusions
Post-operative epidural hematoma causing catastrophic neurological deficit is a rare complication after spinal surgery. The presence of suction wound drains does not appear to prevent the occurrence of this devastating complication.
doi:10.1179/2045772312Y.0000000070
PMCID: PMC3654447  PMID: 23809591
Epidural hematoma; Suction drainage; Spinal cord injuries; Laminectomy; Spinal decompression
3.  Surgical management of spontaneous spinal epidural hematoma 
European Spine Journal  2006;15(6):998-1004.
Spontaneous spinal epidural hematoma (SSEH) is a rare disease entity; its causative factors and the factors determining the outcome are still controversial. We reviewed our clinical experiences and analyzed the various factors related to the outcome for SSEH. We investigated 14 patients (11 men and 3 women) who underwent hematoma removal for SSEH from April 1998 to August 2004. We reviewed age, gender, hypertension, anticoagulant use and the preoperative neurological status using the Japanese Orthopaedics Association score by examining medical records, operative records, pathology reports, and radiographies, retrospectively. We were checking for factors such as the degree of cord compression owing to hematoma and the extent and location of the hematoma. Most patients included in the study were in their twenties or fifties. Four hematoma were located in the cervical region (29%), three were cervicothoracic (21%), four were thoracic (29%) and three were in the lumbar (21%) region and also 12 were located at the dorsal aspect of the spinal cord. In all cases, the neurological outcome improved after the surgical operation. There was a statistically significant difference between the incomplete and complete neurological injury for the preoperative status (P<0.05). The neurological outcome was good in those cases that had their hematoma removed within 24 h (P<0.05). The patients with incomplete neurological injury who had a surgical operation performed within 12 h had an excellent surgical outcome (P<0.01). Spontaneous spinal epidural hematoma was favorably treated by the means of a surgical operation. The favorable factors for SSEH operations were incomplete neurological injury at the time of the preoperative status and the short operative time interval.
doi:10.1007/s00586-005-0965-8
PMCID: PMC3489451  PMID: 16758110
Epidural hematoma; Cord injury; Operative time interval; Spine surgery
4.  Is Closed-suction Drainage Necessary for Single-level Lumbar Decompression?: Review of 560 Cases 
Background
Closed-suction drainage is commonly used for prevention of postoperative hematoma and associated neurologic compromise after lumbar decompression, but it remains unclear whether suction drainage reduces postoperative complications.
Questions/purposes
We evaluated the efficacy of closed-suction drainage in single-level lumbar decompression surgery.
Patients and Methods
We retrospectively reviewed 560 patients who underwent single-level lumbar decompression or discectomy. We routinely used closed-suction drainage in all spinal surgeries until July 2003, and thereafter, we did not use drains in single-level lumbar decompression surgery. These two groups (298 patients in the group that received drains, 262 in the group that did not receive drains) were compared for rates of wound infection and epidural hematoma.
Results
Mean operating time (55 versus 56 minutes) and intraoperative blood loss (64 versus 57 mL) were not different between the two groups. None of 560 patients had a wound infection requiring surgical intervention. The rate of postoperative hematoma was 0.7% in the group that received drains (two of 298 patients) and 0% in the group that did not receive drains (zero of 262 patients).
Conclusions
In this study, the risk of wound infection and hematomas in single-level lumbar decompression surgery was not influenced by use of a drain. The use of postoperative wound drainage in patients with potential risk for epidural bleeding in situations such as multiple-level decompression, instrumentation surgery, anticoagulant therapy, trauma, and tumors or metastases needs additional study.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1235-6
PMCID: PMC3049608  PMID: 20091386
5.  Delayed Postoperative Epidural Hematoma Presenting Only with Vesicorectal Disturbance 
Case Reports in Orthopedics  2013;2013:861961.
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
doi:10.1155/2013/861961
PMCID: PMC3773434  PMID: 24073350
6.  Clinical outcomes of microendoscopic decompression surgery for cervical myelopathy 
European Spine Journal  2009;19(3):487-493.
Retrospective study on the results of microendoscopic decompression surgery for the treatment of cervical myelopathy. The purpose of this study was to describe the microendoscopic laminoplasty (MEL) technique as the surgical method in the treatment of cervical myelopathy, and to document the clinical outcomes for MEL surgery. Endoscopic surgery poses several challenges for the aspiring endoscopic surgeons, the most critical of which is mastering hand–eye coordination. With training in live animal and cadaver surgery, the technical progress has reduced the problem of morbidity following surgery. The authors have performed microendoscopic decompression surgery on more than 2,000 patients for lumbar spinal canal stenosis. Fifty-one patients underwent the posterior decompression surgery using microendoscopy for cervical myelopathy at authors’ institute. The average age was 62.9 years. The criteria for exclusion were cervical myelopathy with tumor, trauma, severe ossification of posterior longitudinal ligament, rheumatoid arthritis, pyogenic spondylitises, destructive spondylo-arthropathies, and other combined spinal lesions. The items evaluated were neurological evaluation, recovery rates; these were calculated following examination using the Hirabayashi’s method with the criteria proposed by the Japanese Orthopaedic Association scoring system (JOA score). The mean follow-up period was 20.3 months. The average of JOA score was 10.1 points at the initial examination and 13.6 points at the final follow-up. The average recovery rate was 52.5%. The recovery rate according to surgical levels was, respectively, 56.5% in one level, 46.3% in two levels and 54.1% in more than three levels. The complications were as follows: one patient sustained a pin-hole-like dura mater injury inflicted by a high-speed air-drill during surgery, one patient developed an epidural hematoma 3 days after surgery, and two patients had the C5 nerve root palsy after surgery. The epidural hematoma was removed by the microendoscopy. All two C5 palsy improved with conservative therapy, such as a neck collar. These four patients on complications have returned to work at the final follow-up. This observation suggests that the clinical outcomes of microendoscopic surgery for cervical myelopathy were excellent or showed good results. This minimally invasive technique would be helpful in choosing a surgical method for cervical myelopathy.
doi:10.1007/s00586-009-1233-0
PMCID: PMC2899765  PMID: 19956984
Cervical spine; Clinical outcome; Endoscopic surgery; Laminoplasty; Myelopathy
7.  Intracranial hemorrhage following lumbar spine surgery 
European Spine Journal  2012;21(10):2091-2096.
Background
Intracranial hemorrhage is a serious but rare complication of spinal surgery, which can occur in the intracerebral, cerebellar, epidural, or subdural compartment.
Purpose
To describe patients with intracranial hemorrhage after lumbar spinal surgery and present clinical and diagnostic imaging findings.
Methods
In this retrospective study, medical records of 1,077 patients who underwent lumbar spinal surgery in our tertiary referral neurosurgery center between January 2003 and September 2010 were studied. The original presentations of the patients before the surgical intervention were herniated lumbar disc, spinal canal stenosis, spondylolisthesis, lumbar spinal trauma, and lumbar spine and epidural tumor. The operations performed consisted of discectomy, multiple level laminectomy, stabilization and fusion, lumbar instrumentation, and lumbar spinal and epidural tumor resection.
Results
Four cases developed intracranial hemorrhage including acute subdural hematoma (one case), epidural hematoma (one case), and remote cerebellar hemorrhage (two cases). The clinical and diagnostic imaging characteristics along with treatments performed and outcomes of these four patients are described and the pertinent literature regarding post-lumbar spinal surgery intracranial hemorrhages is reviewed.
Conclusion
Though rare, intracranial hemorrhage can occur following lumbar spinal surgery. This complication may be asymptomatic or manifest with intense headache at early stages any time during the first week after surgery. Dural tear, bloody CSF leakage, focal neurologic symptoms, and headache are indicators of potential intracranial hemorrhage, which should be considered during or following surgery and necessitate diagnostic imaging.
doi:10.1007/s00586-012-2187-1
PMCID: PMC3463703  PMID: 22349967
Intracranial hemorrhage; Lumbar spine surgery; Remote cerebellar hemorrhage; Subdural hematoma; Epidural hematoma
8.  Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient -A case report- 
Korean Journal of Anesthesiology  2011;61(6):524-527.
The addition of thoracic epidural anesthesia to general anesthesia during cardiac surgery may have a beneficial effect on clinical outcome. However, epidural catheter insertion in a patient anticoagulated with heparin may increase the risk of epidural hematoma. We report a case of epidural hematoma in a 55-year-old male patient who had a thoracic epidural placed under general anesthesia preceding uneventful mitral valve replacement and tricuspid valve annular plasty. During the immediate postoperative period and first postoperative day, prothrombin time (PT) and activate partial thromboplastin time (aPTT) were mildly prolonged. On the first postoperative day, he complained of motor weakness of the lower limbs and back pain. An immediate MRI of the spine was performed and it revealed an epidural hematoma at the T5-6 level. Rapid surgical decompression resulted in a recovery of his neurological abnormalities to near normal levels. Management and preventing strategies of epidural hematoma are discussed.
doi:10.4097/kjae.2011.61.6.524
PMCID: PMC3249578  PMID: 22220233
Analgesia; Epidural; Hematoma; Postoperative complications; Spinal
9.  Early postoperative MRI in detecting hematoma and dural compression after lumbar spinal decompression: prospective study of asymptomatic patients in comparison to patients requiring surgical revision 
European Spine Journal  2010;19(12):2216-2222.
Early postoperative MRI after spinal surgery is difficult to interpret because of confounding postoperative mass effects and frequent occurrence of epidural hematomas. Purpose of this prospective study is to evaluate prevalence, extent and significance of hematoma in the first postoperative week in asymptomatic patients after decompression for lumbar stenosis and to determine the degree of clinically significant dura compression by comparing with the patients with postoperative symptoms. MRI was performed in 30 asymptomatic patients (47 levels) in the first week after lumbar spine decompression for degenerative stenosis. Eleven patients requiring surgical revision (16 levels) for symptomatic early postoperative hematoma were used for comparison. In both groups the cross-sectional area of the maximum dural compression (bony stenosis and dural sac expansion) was measured preoperatively and postoperatively by an experienced radiologist. Epidural hematoma was seen in 42.5% in asymptomatic patients (20/47 levels). The median area of postoperative hematoma at the operated level was 176 mm2 in asymptomatic patients and 365 mm2 in symptomatic patients. The median cross-sectional area of the dural sac at the operated level was 128.5 and 0 mm2 in asymptomatic and symptomatic patients, respectively, at the site of maximal compression. In the symptomatic group 75% of the patients had a maximal postoperative dural sac area of 58.5 mm2 or less, whereas in the asymptomatic group 75% of patients with epidural hematoma had an area of 75 mm2 or more. The size of hematoma and the degree of dural sac compression were significantly larger in patients with symptoms needing surgical revision. Dural sac area of less than 75 mm2 in early postoperative MRI was found to be the threshold for clinical significance.
doi:10.1007/s00586-010-1483-x
PMCID: PMC2997206  PMID: 20556438
Epidural hematoma; Early postoperative MRI; Spinal stenosis; Neural compression
10.  Case Report: Cauda Equina Syndrome Associated With an Interspinous Device 
Background
Although postoperative spinal epidural hematoma (SEH) is not uncommon, hematomas that require surgery are rare. Cauda equina syndrome (CES) may be associated with postoperative SEH. In these cases, early recognition and emergency decompression can prevent further damage and better neurologic recovery.
Case Description
A 41-year-old man underwent two-level discectomy with insertion of an interspinous spacer at L3-4 and L4-5 because of low back pain and radiculopathy. Eight hours after the operation, the patient developed CES. MRI revealed SEH compressing posteriorly at the L3-4 level. On emergency decompression and hematoma evacuation, the interspinous spacer had obstructed the laminotomy site at L3-4 completely, blocking drainage to the drain. The patient experienced complete neurologic recovery by 2 months followup.
Literature Review
Many studies report risk factors for SEH. However, postoperative SEH can also be encountered in patients without these risks. One study reported a critical ratio (preoperative versus postoperative cross-sectional area) correlated with postoperative symptoms, especially in those with CES. The propensity to develop CES is likely dependent on a number of patient-specific factors.
Clinical Relevance
Surgeons should be aware that patients without risk factors may develop acute CES. Wider laminotomy (larger than half of the device size) may help to prevent this complication when one uses the compressible type of device, especially in patients with relatively small lamina.
doi:10.1007/s11999-011-2031-7
PMCID: PMC3348300  PMID: 21870210
11.  Extensive Postoperative Epidural Hematoma After Full Anticoagulation: Case Report and Review of the Literature 
Background/Objective:
A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation.
Methods:
Case report.
Findings:
After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma.
Results:
Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy.
Conclusions:
Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
PMCID: PMC2031966  PMID: 17684896
Spinal stenosis, lumbar; Spinal decompression; Anticoagulation; Epidural hematoma; Laminectomy
12.  Post-traumatic Lumbar Epidural Hematoma with Neurology: Report of 1 Case 
Asian Spine Journal  2011;5(2):130-132.
The purpose of this study was to report a case with post-traumatic spinal epidural hematomas with abnormal neurologic findings, which is uncommon. A 40-year-old man presented at our clinic after a blunt trauma caused by a traffic accident in which he was a pedestrian. After admission, abnormal neurologic symptoms developed including loss of sensation and motor function in his left lower extremity. Magnetic resonance imaging demonstrated a spinal epidural hematoma with 40% canal stenosis at the L5-S1 level. Decompression including hematoma evacuation was done. Symptoms started to be reduced 18 days after operation. He was treated conservatively with medications and all symptoms resolved completely during admission and there were no further neurologic sequelae. Post-traumatic lumbar spinal epidural hematoma with abnormal neurologic findings is an uncommon condition that may present belatedly after trauma with significant neurologic compromise.
doi:10.4184/asj.2011.5.2.130
PMCID: PMC3095803  PMID: 21629489
Lumbar spine; Epidural hematoma; Neurology
13.  Epidural hematoma occurred by massive bleeding intraoperatively in cesarean section after combined spinal epidural anesthesia -A case report- 
Korean Journal of Anesthesiology  2011;61(4):336-340.
We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.
doi:10.4097/kjae.2011.61.4.336
PMCID: PMC3219782  PMID: 22110889
Blood coagulation disorder; Cesarean section; Epidural anesthesia; Epidural hematoma; Postpartum hemorrhage; Spinal anesthesia
14.  Acute spinal subdural hematoma complicating lumbar decompressive surgery 
Study design: A case report.
Objective: To report a rare case of acute spinal subdural hematoma (SSH) complicating lumbar spine surgery, its characteristic presenting symptoms, diagnostic imaging, possible cause, and pitfall in management.
Methods: A 59-year-old woman with lumbar spinal instability and stenosis underwent laminectomy and decompression at L3–L5 with instrumentation and fusion from L3–S1.
Results: Immediately following surgery, the patient presented with incapacitating pain of both lower extremities from the mid-thigh downward, which was not relieved by narcotic analgesia and was disproportional to surgical trauma. Left ankle and great toes weakness was detected at postoperative day 2 and deteriorated on day 6. Magnetic resonance imaging was performed urgently and revealed a characteristic SSH with thecal sac compression at the level of L2, proximal to the laminectomy. Emergency decompression and evacuation of the hematoma was performed. The patient had partial recovery 6 weeks postoperatively.
Conclusion: Acute SSH is a rare complication of lumbar spine surgery. This diagnosis must be considered when severe leg pain, unresolved with analgesia and disproportional to surgical trauma, with neurological deterioration occurring after lumbar spine surgery. Magnetic resonance imaging is the imaging modality of choice to assist in the differential diagnosis of an SSH. Early surgical decompression is necessary for optimal neurological recovery.
doi:10.1055/s-0031-1298602
PMCID: PMC3503516  PMID: 23236307
15.  Spontaneous cervical epidural hematoma of idiopathic etiology: Case report and review of literature 
Context
Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to acute onset of neurological deficits, which if not recognized early can have catastrophic consequences. The definition and pathophysiology of this condition remain controversial. High index of suspicion followed by T2-weighted gradient echo sequences are particularly useful in early diagnosis. Management consists of prompt surgical decompression of the hematoma though a recent trend is toward non-surgical treatment.
Findings
A 70-year-old man presented with acute onset neck pain with a radicular component and rapidly progressive quadriparesis. Magnetic resonance imaging revealed a posteriorly located cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery to near normal function occurred within 24 hours of surgery.
Conclusion
SSEH in its true idiopathic form is a rare pathologic entity. Because of the high risk of poor outcome without treatment, SSEH should be a diagnostic possibility when presentation is even slightly suggestive. Prompt surgical evacuation of the hematoma leads to a favorable neurological outcome, whereas delay in treatment can be disastrous. The role of conservative management needs to be proven and should be tailored on an individual basis.
doi:10.1179/2045772312Y.0000000001
PMCID: PMC3304555  PMID: 22333537
Tetraparesis; Tetraplegia; Paralysis; Myelopathy; Laminectomy; Neurologic manifestations; Progressive; Spinal cord compression; Cervical; Hematoma; Idiopathic spontaneous spinal epidural hematoma
16.  First aid and treatment for cervical spinal cord injury with fracture and dislocation 
Indian Journal of Orthopaedics  2007;41(4):300-304.
Background:
Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.
Materials and Methods:
Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.
Results:
All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.
Conclusion:
First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.
doi:10.4103/0019-5413.36991
PMCID: PMC2989519  PMID: 21139782
Cervical spine; first aid; spinal cord injury; surgical treatment
17.  Clinical Outcomes of Spontaneous Spinal Epidural Hematoma : A Comparative Study between Conservative and Surgical Treatment 
Objective
The incidence of spontaneous spinal epidural hematoma (SSEH) is rare. Patients with SSEH, however, present disabling neurologic deficits. Clinical outcomes are variable among patients. To evaluate the adequate treatment method according to initial patients' neurological status and clinical outcome with comparison of variables affecting the clinical outcome.
Methods
We included 15 patients suffered from SSEH. Patients were divided into two groups by treatment method. Initial neurological status and clinical outcomes were assessed by the American Spinal Injury Association (ASIA) impairment scale. Also sagittal hematoma location and length of involved segment was analyzed with magnetic resonance images. Other factors such as age, sex, premorbid medication and duration of hospital stay were reviewed with medical records. Nonparametric statistical analysis and subgroup analysis were performed to overcome small sample size.
Results
Among fifteen patients, ten patients underwent decompressive surgery, and remaining five were treated with conservative therapy. Patients showed no different initial neurologic status between treatment groups. Initial neurologic status was strongly associated with neurological recovery (p=0.030). Factors that did not seem to affect clinical outcomes included : age, sex, length of the involved spinal segment, sagittal location of hematoma, premorbid medication of antiplatelets or anticoagulants, and treatment methods.
Conclusion
For the management of SSEH, early decompressive surgery is usually recommended. However, conservative management can also be feasible in selective patients who present neurologic status as ASIA scale E or in whom early recovery of function has initiated with ASIA scale C or D.
doi:10.3340/jkns.2012.52.6.523
PMCID: PMC3550419  PMID: 23346323
Spinal epidural hematoma; Surgery; Conservative management; Outcome
18.  Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery 
European Spine Journal  2003;13(1):9-13.
Aim: To determine the risk of postoperative hemorrhage during a 3-year period of early postoperative administration of nadroparin (Fraxiparin) plus compression stockings in a large cohort of patients who underwent spinal surgery. Methods: A total of 1,954 spinal procedures at different levels (503 cervical, 152 thoracic and 1,299 lumbar), performed between June 1999 and 2002 at the Department of Neurosurgery, Johann-Wolfgang-Goethe University Frankfurt, were included in this study. To prevent venous thromboembolic events (VTE), all patients were routinely treated subcutaneously with 0.3 ml of early (less than 24 h) postoperative nadroparin calcium (Fraxiparin) (2850 IU anti-Xa, Sanofi Winthrop Industrie, France) plus intra- and postoperative compression stockings until discharge. The occurrence of a postoperative hematoma (defined as a hematoma requiring surgical evacuation because of space occupation and/or neurological deterioration) and a deep venous thrombosis (DVT) were recorded in a database and analyzed retrospectively. Results: 13 (0.7%) of the 1,954 spinal operations were complicated by major postoperative hemorrhages. In 5 of the 13 patients (38.5%) the hemorrhage occurred on the day of surgery before the administration of nadroparin. Thus, the hemorrhage rate of patients receiving nadroparin was 0.4% (8/1,949). Ten (77%) of the 13 patients with major postoperative hematoma showed a progressive neurological deficit, which resolved in 6 patients and resulted in a hematoma-related morbidity of 31% (4/13). Only 1 patient (0.05%) in this series developed a clinically evident DVT, and none of the patients suffered from pulmonary embolus during the hospital stay. Conclusion: Although retrospective, this is to date the largest study providing information about the hemorrhage rate associated with early postoperative anticoagulation following spinal surgery. The results confirm that early postoperative pharmacological thromboembolic prophylaxis using nadroparin in patients with spinal surgery is not associated with an increased risk of postoperative hemorrhage.
doi:10.1007/s00586-003-0642-8
PMCID: PMC3468029  PMID: 14615928
Spinal surgery; Hemorrhage; Thrombosis; Thromboembolism; Heparin
19.  Surgery for Bilateral Large Intracranial Traumatic Hematomas: Evacuation in a Single Session 
Objective
Management guidelines for single intracranial hematomas have been established, but the optimal management of multiple hematomas has little known. We present bilateral traumatic supratentorial hematomas that each has enough volume to be evacuated and discuss how to operate effectively it in a single anesthesia.
Methods
In total, 203 patients underwent evacuation and/or decompressive craniectomies for acute intracranial hematomas over 5 years. Among them, only eight cases (3.9%) underwent operations for bilateral intracranial hematomas in a single session. Injury mechanism, initial Glasgow Coma Scale score, types of intracranial lesions, surgical methods, and Glasgow outcome scale were evaluated.
Results
The most common injury mechanism was a fall (four cases). The types of intracranial lesions were epidural hematoma (EDH)/intracerebral hematoma (ICH) in five, EDH/EDH in one, EDH/subdural hematoma (SDH) in one, and ICH/SDH in one. All cases except one had an EDH. The EDH was addressed first in all cases. Then, the evacuation of the ICH was performed through a small craniotomy or burr hole. All patients except one survived.
Conclusion
Bilateral intracranial hematomas that should be removed in a single-session operation are rare. Epidural hematomas almost always occur in these cases and should be removed first to prevent the hematoma from growing during the surgery. Then, the other hematoma, contralateral to the EDH, can be evacuated with a small craniotomy.
doi:10.3340/jkns.2014.55.6.348
PMCID: PMC4166331  PMID: 25237431
Intracranial hemorrhages; Epidural hematoma; Craniotomy; Multiple lesions
20.  Idiopathic Hypertrophic Spinal Pachymeningitis : Report of Two Cases and Review of the Literature 
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory disease characterized by hypertrophic inflammation of the dura mater and various clinical courses that are from myelopathy. Although many associated diseases have been suggested, the etiology of IHSP is not well understood. The ideal treatment is controversial. In the first case, a 55-year-old woman presented back pain, progressive paraparesis, both leg numbness, and voiding difficulty. Initial magnetic resonance imaging (MRI) demonstrated an anterior epidural mass lesion involving from C6 to mid-thoracic spine area with low signal intensity on T1 and T2 weighted images. We performed decompressive laminectomy and lesional biopsy. After operation, she was subsequently treated with steroid and could walk unaided. In the second case, a 45-year-old woman presented with fever and quadriplegia after a spine fusion operation due to lumbar spinal stenosis and degenerative herniated lumbar disc. Initial MRI showed anterior and posterior epidural mass lesion from foramen magnum to C4 level. She underwent decompressive laminectomy and durotomy followed by steroid therapy. However, her conditions deteriorated gradually and medical complications occurred. In our cases, etiology was not found despite through investigations. Initial MRI showed dural thickening with mixed signal intensity on T1- and T2-weighted images. Pathologic examination revealed chronic nonspecific inflammation in both patients. Although one patient developed several complications, the other showed slow improvement of neurological symptoms with decompressive surgery and steroid therapy. In case of chronic compressive myelopathy due to the dural hypertrophic change, decompressive surgery such as laminectomy or laminoplasty may be helpful as well as postoperative steroid therapy.
doi:10.3340/jkns.2011.50.4.392
PMCID: PMC3243847  PMID: 22200026
Idiopathic hypertrophic spinal pachymeningitis; Spinal cord compression; Chronic nonspecific inflammation; Dural thickening
21.  Delayed Onset Neurological Deterioration due to a Spinal Epidural Hematoma after a Spine Fracture 
Asian Spine Journal  2007;1(2):98-101.
There are no reports of a 7-day delay in the onset of neurological deterioration because of a spinal epidural hematoma (SEH) after a spinal fracture. A hematoma was detected from the T12 to L2 area in a 36-year-old male patient with a T12 burst fracture. On the same day, the patient underwent in situ posterior pedicle instrumentation on T10-L3 with no additional laminectomy. On the seventh postoperative day, the patient suddenly developed weakness and sensory changes in both extremities, together with a sharp pain. A MRI showed that the hematoma had definitely increased in size. A partial laminectomy was performed 12 hours after the onset of symptoms. Two days after surgery, recovery of neurological function was noted. This case shows that spinal surgeons need to be aware of the possible occurrence of a delayed aggravated SEH and neurological deterioration after a spinal fracture.
doi:10.4184/asj.2007.1.2.98
PMCID: PMC2857477  PMID: 20411132
Spinal epidural hematoma; Spine fracture; Neurology
22.  Bilateral asynchronous acute epidural hematoma : a case report 
Background
Bilateral extradural hematomas have only rarely been reported in the literature. Even rarer are cases where the hematomas develop sequentially, one after removal of the other. Among 187 cases of operated epidural hematomas during past 4 years in our hospital, we found one case of sequentially developed bilateral epidural hematoma.
Case Presentation
An 18-year-old conscious male worker was admitted to our hospital after a fall. After deterioration of his consciousness, an emergency brain CT scan showed a right temporoparietal epidural hematoma. The hematoma was evacuated, but the patient did not improve afterwards. Another CT scan showed contralateral epidural hematoma and the patient was reoperated. Postoperatively, the patient recovered completely.
Conclusions
This case underlines the need for monitoring after an operation for an epidural hematoma and the need for repeat brain CT scans if the patient does not recover quickly after removal of the hematoma, especially if the first CT scan has been done less than 6 hours after the trauma. Intraoperative brain swelling can be considered as a clue for the development of contralateral hematoma.
doi:10.1186/1471-227X-3-1
PMCID: PMC317469  PMID: 14697100
bialteral; epidual; hematoma
23.  Neurological deterioration after laminectomy for spondylotic cervical myeloradiculopathy: the putative role of spinal cord ischaemia. 
Most cases of neurological deterioration after laminectomy for cervical radiculomyelopathy occur several weeks to months postoperatively, except when there has been direct trauma to the spinal cord or nerve roots during surgery. Four patients are described who developed episodes of neurological deterioration during the postoperative recovery period that could not be attributed to direct intraoperative trauma nor to epidural haematoma or instability of the cervical spine as a consequence of laminectomy. Following laminectomy for cervical radiculomyelopathy four patients were unchanged neurologically from their pre-operative examinations, but as they were raised into the upright position for the first time following surgery focal neurological deficits referrable to the spinal cord developed. Hypotension was present in all four cases during these episodes and three of the four patients had residual central cervical cord syndromes. These cases represent the first reported instances of spinal cord ischaemia occurring with post-operative hypotensive episodes after decompression for cervical spondylosis.
PMCID: PMC1033084  PMID: 3404170
24.  Perioperative complications with rhBMP-2 in transforaminal lumbar interbody fusion 
European Spine Journal  2010;20(4):612-617.
Bone morphogenetic protein (BMP) is commonly used as an ICBG substitute for transforaminal lumbar interbody spine fusion (TLIF). However, multiple recent reports have raised concerns regarding a substantial incidence of perioperative radiculopathy. Also, given the serious complications reported with anterior cervical BMP use, risks related to swelling and edema with TLIF need to be clarified. As TLIF related complications with rhBMP-2 have generally been reported in small series or isolated cases, without a clear denominator, actual complication rates are largely unknown. The purpose this study is to characterize perioperative complications and complication rates in a large consecutive series of TLIF procedures with rhBMP-2. We reviewed inpatient and outpatient medical records for a consecutive series of 204 patients [113 females, 91 males, mean age 49.3 (22–79) years] who underwent TLIF using rhBMP-2 between 2003 and 2007. Complications observed within a 3-month perioperative interval were categorized as to etiology and severity. Wound problems were delineated as wound infection, hematoma/seroma or persistent drainage/superficial dehiscence. Neurologic deficits and radiculopathies were analyzed to determine the presence of a clear etiology (screw misplacement) and identify any potential relationship to rhBMP-2 usage. Complications were observed in 47 of 204 patients (21.6%) during the 3-month perioperative period. Major complications occurred in 13 patients (6.4%) and minor complications in 34 patients (16.7%). New or more severe postoperative neurologic complaints were noted in 13 patients (6.4%), 6 of whom required additional surgery. These cases included one malpositioned pedicle screw and one epidural hematoma. In four patients (2.0%), localized seroma/hematoma in the area of the foramen caused neural compression, and required revision. In one additional patient, vertebral osteolysis caused foraminal narrowing and radiculopathy, but resolved without further surgery. Persistent radiculopathy without clear etiology on imaging studies was seen in six patients. Wound related problems were seen in six patients (2.9%), distributed as wound infection (3), hematoma/seroma (1) and persistent drainage/dehiscence (2). Overall, this study demonstrates a modest complication rate for TLIF using rhBMP-2. While perioperative complications which appeared specific to BMP usage were noted, they occurred infrequently. It will be necessary to weigh this incidence of complications against the complication rate associated with ICBG harvest and any differential benefit in obtaining a solid arthrodesis.
doi:10.1007/s00586-010-1494-7
PMCID: PMC3065615  PMID: 20582554
Bone graft substitute; Bone morphogenetic protein; Transforaminal interbody fusion; Morbidity; Spine fusion
25.  Solitary spinal epidural cavernous angioma: report of nine surgically treated cases and review of the literature 
European Spine Journal  2012;22(3):542-547.
Purpose
We intend to report the largest series of spinal epidural cavernomas (SEC), discuss their clinical features, imaging characteristics, surgical findings, outcome analysis and compare them with similar reports in the literature.
Methods
Among the cases of spinal tumors treated surgically by the authors, there have been nine cases of SEC’s. All the data were collected prospectively and the cases have been followed after surgery up to the time of this analysis.
Results
There were six female and three male patients with the ages ranging between 13 and 74 years. The lesions were located in the thoracic spine (4 cases), lumbar spine (4 cases) and one at the sacral level. Clinical presentations included acute spinal pain and paraparesis in two, low back pain and radiculopathy in five, and slowly progressive myelopathy in the other two cases. The lesion was iso-intense with the spinal cord in T1W images and hyperintense in T2W images and showed strong homogeneous enhancement after contrast medium injection in most of our cases. In the presence of hemorrhage inside the lesion, it was hyperintense in both T1W and T2W MR sequences as in our case 6. In the single case presenting with acute hemorrhage, epidural hematoma was the only finding, our case 1. Complete surgical removal was achieved in all our cases, and confirmed by postoperative MRI.
Conclusion
SEC is hard to be differentiated from other epidural spinal lesions before intervention but should be considered in the list of differential diagnosis regarding its favorable outcome.
doi:10.1007/s00586-012-2526-2
PMCID: PMC3585645  PMID: 23053760
Cavernous angioma; Magnetic resonance imaging; Spinal epidural cavernoma; Spinal epidural lesion

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