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1.  Postoperative Spinal Epidural Hematoma: Risk Factor and Clinical Outcome 
Yonsei Medical Journal  2006;47(3):326-332.
We report a series of epidural hematomas which cause neurologic deterioration after spinal surgery, and have taken risk factors and prognostic factors into consideration. We retrospectively reviewed the database of 3720 cases of spine operation in a single institute over 7 years (1998 April-2005 July). Nine patients who demonstrated neurologic deterioration after surgery and required surgical decompression were identified. Factors postulated to increase the postoperative epidural hematoma and to improve neurologic outcome were investigated. The incidence of postoperative epidural hematoma was 0.24%. Operation sites were cervical 3 cases, thoracic 2 cases, and lumbar 4 cases. Their original diagnoses were tumor 3 cases, cervical stenosis 2 cases, lumbar stenosis 3 cases and herniated lumbar disc 1case. The symptoms of epidural hematomas were neurologic deterioration and pain. After decompression, clinical outcome revealed complete recovery in 3 cases (33.3%), incomplete recovery in 5 cases (55.6%) and no change in 1 case (11.1%). Factors increasing the risk of postoperative epidural hematoma were coagulopathy from medical illness or anticoagulation therapy (4 cases, 44.4%) and highly vascularized tumor (3 cases, 33.3%). The time interval to evacuation of complete recovery group (29.3 hours) was shorter than incomplete recovery group (66.3 hours). Patients with coagulopathy and highly vascularized tumor were more vulnerable to spinal epidural hematoma. The postoperative outcome was related to the preoperative neurological deficit and the time interval to the decompression.
doi:10.3349/ymj.2006.47.3.326
PMCID: PMC2688151  PMID: 16807981
Clinical outcome; risk factor; postoperative; spinal epidural hematoma; spine surgery
2.  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
3.  Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report 
Cases Journal  2009;2:6732.
Introduction
Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery.
Case presentation
We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively.
Conclusion
A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.
doi:10.1186/1757-1626-2-6732
PMCID: PMC2740288  PMID: 19829853
4.  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
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.  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
7.  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
8.  Spinal subarachnoid hematoma in a woman with HELLP syndrome: a case report 
Introduction
Subarachnoid hemorrhages of spinal origin are extremely rare during pregnancy. We present the case of a patient with hemolytic anemia, elevated liver enzymes and low platelet count (the so-called HELLP syndrome), a potentially life-threatening complication associated with pre-eclampsia, who presented with an idiopathic spinal subarachnoid hematoma.
Case presentation
At 29 gestational weeks, a 35-year-old Japanese woman was diagnosed with HELLP syndrome based on bilateral leg paralysis, diminished sensation and reflexes, and laboratory findings. The pregnancy was immediately brought to an end by Cesarean delivery. Post-operatively, an MRI scan revealed a space-occupying lesion in her thoracic spinal canal. Emergency decompression was followed by total laminectomy. A subarachnoid hematoma, partially extending as far as the ventral side, was removed. After thorough washing and drain placement, the operation was completed with the suturing of artificial dura mater. Eight months post-operatively, her lower extremity sensation had improved to a score of 8 out of 10, but improvements in her muscular strength were limited to slight gains in her toes. MRI scans taken two months post-operatively revealed edematous spinal cord changes within her medulla.
Conclusions
A subarachnoid hematoma during pregnancy is extremely rare, possibly due to increased coagulability during pregnancy. However, this complication is potentially devastating should a clot compress the spinal cord or cauda equina. While several causes of hematoma have been proposed, we speculate that the factors underlying hemorrhagic diathesis in our case were the decreased platelet count characteristic of HELLP syndrome and vascular fragility due to elevated estrogen levels, in addition to increased abdominal pressure during pregnancy and pressure from the gravid uterus resulting in ruptured vessels around the spinal cord. In cases displaying a progressive lesion and severe neurological signs, prompt decompression is crucial.
doi:10.1186/1752-1947-6-152
PMCID: PMC3411404  PMID: 22691165
9.  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
10.  Cauda equina lesions as a complication of spinal surgery 
European Spine Journal  2009;19(3):451-457.
Although the most common aetiology of cauda equina lesions is lumbar intervertebral disc herniation, iatrogenic lesions may also be the cause. The aim of this study was to identify and present patients in whom cauda equina lesions occurred after spinal surgery. From the author’s series of patients with cauda equina lesions, those with the appearance of sacral symptoms after spinal surgery were identified. To demonstrate lesions more objectively, electrodiagnostic studies were performed in addition to history and clinical examination. Imaging studies were also reviewed. Of 69 patients from the series, 11 patients in whom a cauda equina lesion developed after spinal surgery were identified. The aetiology comprised surgery for herniated intervertebral disc in 5 (4 performed by a single surgeon), spinal stenosis surgery in 4, and postoperative lumbar epidural haematoma in 2 patients (each performed by a different surgeon). Proportion of spinal surgeries with this complication varied from 0 to 6.6‰ in different centres. Patients with iatrogenic cauda equina lesion were significantly older (p < 0.001), and reported more severe urinary, but similar bowel and sexual symptoms compared to other patients in the series. In conclusion the study identified spinal surgery as the cause of approximately 15% of cauda equina lesions. More than a third of lesions developed after procedures performed by a single surgeon. Most of the remaining lesions could probably be avoided by better surgical technique (e.g. the use of a high-speed drill instead of a Kerrison rongeur in patients with severe spinal stenosis), or prevented by closer postoperative monitoring (e.g. in patients with postoperative lumbar epidural haematoma).
doi:10.1007/s00586-009-1170-y
PMCID: PMC2899755  PMID: 19768646
Cauda equina; Disc herniation; Spinal stenosis; Spinal surgery; Sacral
11.  Symptomatic Extensive Thoracolumbar Epidural Hematoma Following Lumbar Disc Surgery Treated by Single Level Laminectomy 
Asian Spine Journal  2012;6(2):152-155.
Spinal epidural hematomas (SEHs) are rare complications following spine surgery, especially for single level lumbar discectomies. The appropriate surgical management for such cases remains to be investigated. We report a case of an extensive spinal epidural hematoma from T11-L5 following a L3-L4 discectomy. The patient underwent a single level L4. A complete evacuation of the SEH resulted in the patient's full recovery. When presenting symptoms limited to the initial surgical site reveal an extensive postoperative SEH, we propose: to tailor the surgical exposure individually based on preoperative findings of the SEH; and to begin the surgical exposure with a limited laminectomy focused on the symptomatic levels that may allow an efficient evacuation of the SEH instead of a systematic extensive laminectomy based on imaging.
doi:10.4184/asj.2012.6.2.152
PMCID: PMC3372553  PMID: 22708022
Epidural; Hematoma; Spine; Surgery; Management; Emergency; Postoperative
12.  Spinal Epidural Hematoma after Pain Control Procedure 
Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.
doi:10.3340/jkns.2010.48.3.281
PMCID: PMC2966734  PMID: 21082060
Spinal epidural hematoma; Pain control procedure; Surgical evacuation
13.  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
14.  Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation 
Background:
Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature.
Methods:
We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany).
Results:
After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up.
Conclusions:
Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.
doi:10.4103/2152-7806.131106
PMCID: PMC4033759  PMID: 24872917
Chronic epidural hematoma; endoscopic; interlaminar; lumbar; spinal manipulation
15.  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
16.  Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report 
Background
Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.
Case presentation
We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.
Conclusions
The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.
doi:10.1186/1471-227X-11-10
PMCID: PMC3160384  PMID: 21794133
17.  Cauda Equina Syndrome Following Decompression for Spinal Stenosis 
Global Spine Journal  2011;1(1):15-18.
Cauda equina syndrome following decompression for spinal stenosis appears to occur more commonly than the literature suggests. A large series of spinal stenosis decompressions was reviewed. Based on these findings, a theory is put forth as to the cause of this complication. One hundred seventy-five cases of decompression for spinal stenosis done over a 2.5-year period were reviewed. Follow-up was 1year to 2 years and 4 months. There were 14 cases of postoperative urinary retention, for an incidence of 8%. Of those, five were ultimately diagnosed with cauda equina syndrome, for an incidence of 2.8%. Of the nine cases that were not diagnosed as cauda equina syndrome, five resolved spontaneously over 2 to 6 weeks. The remaining four were diagnosed as having mechanical urinary problems (e.g., prostate or prolapsed bladder) that required surgical treatment. Anal sphincter monitoring at the time of surgery was not predictive in those patients who developed cauda equina syndrome. All patients who developed cauda equina syndrome improved over 3 to 9 months, but none completely resolved. Three cases underwent further decompression with no apparent improvement. Cauda equina syndrome occurs in 2.8% of decompressions for spinal stenosis.
doi:10.1055/s-0031-1296051
PMCID: PMC3864468  PMID: 24353932
cauda equina syndrome; spinal stenosis; decompression; postoperative complications
18.  Delayed Spinal Epidural Hematoma after En Block Spondylectomy for Vertebral Ewing's Sarcoma 
Asian Spine Journal  2010;4(2):118-122.
We report here on a case of a 23-year-old male who received en block spondylectomy for a vertebral Ewing's sarcoma at our hospital. Nine days after surgery, he presented with severe back pain and motor weakness of the lower extremities. Based on the physical examination and the computed tomography scan, he was diagnosed with acute cauda equina syndrome that was caused by compression from an epidural hematoma. His neurological functions recovered after emergency evacuation of the hematoma. This case showed that extensive surgery for a malignant vertebral tumor has a potential risk of delayed epidural hematoma and acute cauda equina syndrome and this should be treated with emergency evacuation.
doi:10.4184/asj.2010.4.2.118
PMCID: PMC2996623  PMID: 21165315
Epidural hematoma; Ewing's sarcoma; Spine; En block spondylectomy
19.  Brain herniation induced by drainage of subdural hematoma in spontaneous intracranial hypotension 
Asian Journal of Neurosurgery  2013;8(2):112-115.
Spontaneous intracranial hypotension (SIH), typically presents with orthostatic headache, low pressure on lumbar tapping, and diffuse pachymeningeal enhancement on magnetic resonance imaging. SIH is often accompanied by subdural fluid collections, which in most cases responds to conservative treatment or spinal epidural blood patch. Several authors advocate that large subdural hematoma with acute deterioration merits surgical drainage; however, few have reported complications following craniotomy. We describe a complicated case of SIH, which was initially diagnosed as acute subarachnoid hemorrhage with bilateral chronic subdural hematoma (SDH), due to unusual presentation. Burr hole drainage of subdural hematoma was performed due to progressive decrease of consciousness, which then resulted in a huge postoperative epidural hematoma collection. Prompt hematoma evacuation did not restore the patient's consciousness but aggravated downward brain herniation. Trendelenburg position and spinal epidural blood patch achieved a rapid improvement in patient's consciousness. This case indicates that the surgical drainage for chronic SDH in SIH can lead to serious complications and it should be cautiously considered.
doi:10.4103/1793-5482.116390
PMCID: PMC3775182  PMID: 24049555
Chronic subdural hematoma; craniotomy; spontaneous intracranial hypotension; subarachnoid hemorrhage
20.  Deep Venous Thrombosis in Spine Surgery Patients: Incidence and Hematoma Formation 
International Surgery  2012;97(2):150-154.
Deep venous thrombosis (DVT) is a significant health care problem; a variety of factors place spinal surgery patients at high risk for DVT. Our aim is to define the incidence of DVT occurrence in spite of prophylactic measures (mechanical and chemoprophylaxis), and the development of spinal epidural hematoma as a complication of chemoprophylaxis. In a single-center prospective study, 158 patients who underwent spinal surgical procedures were evaluated by clinical evaluation and lower limb Doppler ultrasonography imaging. Only one patient (0.6%) developed DVT; this patient was treated successfully without thrombus progression, with full recanalization. Three patients (1.8%) developed spinal epidural hematoma, but only one required surgical evacuation, and none sustained neurologic deficit. Careful evaluation for DVT risk on an individual basis and good prophylaxis helps to minimize the risk of DVT. The neurosurgeon is thus left to weigh the risks of postoperative hematoma formation against the benefits of protecting against DVT.
doi:10.9738/CC71.1
PMCID: PMC3723201  PMID: 23102081
Deep venous thrombosis; Pulmonary embolism; Spinal surgery; DVT prophylaxis; Low molecular weight heparin; Doppler ultrasonography
21.  Vertebral column decancellation for the management of sharp angular spinal deformity 
European Spine Journal  2011;20(10):1703-1710.
The management goal of sharp angular spinal deformity is to realign the spinal deformity and safely decompress the neurological elements. However, some shortcomings related to current osteotomy treatment for these deformities are still evident. We have developed a new spinal osteotomy technique—vertebral column decancellation (VCD), including multilevel vertebral decancellation, removal of residual disc, osteoclasis of the concave cortex, compression of the convex cortex accompanied by posterior instrumentation with pedicle screws, with the expectation to decrease surgical-related complications. From January 2004 to March 2007, 45 patients (27 males/18 females) with severe sharp angular spinal deformities at our institution underwent VCD. The diagnoses included 29 congenital kyphoscoliosis and 16 Pott’s deformity. Preoperative and postoperative radiographic evaluation was performed. Intraoperative, postoperative and general complications were noted. For a kyphosis deformity, an average of 2.2 vertebrae was decancellated (range, 2–4 vertebrae). The mean preoperative kyphosis was +98.6° (range, 82°–138°), and the mean kyphosis in the immediate postoperative period was +16.4° (range, 4°–30°) with an average postoperative correction of +82.2° (range, 61°–124°). For a kyphoscoliosis deformity, the correction rate was 64% in the coronal plane (from 83.4°–30.0°) postoperatively and 32.5° (61% correction) at 2 years’ follow-up. In the sagittal plane, the average preoperative curve of 88.5° was corrected to 28.6° immediately after surgery and to 31.0° at 2 years’ follow-up. All patients had solid fusion at latest follow-up. Complications were encountered in eight patients (17.8%), including CSF leak (n = 1), deep wound infection (n = 1), epidural hematoma (n = 1), transient neurological deficit (n = 4), and complete paralysis (n = 1). The results of this study show that single-stage posterior VCD is an effective option to manage severe sharp angular spinal deformities.
doi:10.1007/s00586-011-1771-0
PMCID: PMC3175886  PMID: 21424339
Posterior approach; Vertebral column decancellation (VCD); Kyphosis; Kyphoscoliosis; Osteotomy
22.  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
23.  Whole Spontaneous Spinal Epidural Hematoma 
Asian Spine Journal  2014;8(3):361-364.
A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.
doi:10.4184/asj.2014.8.3.361
PMCID: PMC4068858  PMID: 24967052
Epidural hematoma; Naftazone; Spinal hematoma
24.  Thoracic disc herniation causing transient paraplegia coincident with epidural anesthesia: a case report 
Cases Journal  2009;2:6228.
Neurological deficits following epidural or spinal anesthesia are extremely rare. Transient paraplegia following epidural anesthesia in a patient with thoracic disc herniation has been presented. A 44-year-old woman developed paraplegia during the operation for vascular surgery of her legs under epidural anesthesia. Epidural hematoma or spinal cord ischemia was ruled out by magnetic resonance imaging of the thoracic and lumbar spine in which protruded disc at T11-12 level compressing the spinal cord has been verified. Patient responded well to steroid treatment and rehabilitation interventions. Physicians should be aware of preceding disc protrusions, which may have detrimental effects on spinal cord perfusion, as a cause of persistent or transient paraplegia before epidural anesthesia procedure. MRI is a valuable imaging option to rule out epidural anesthesia complications and coexisting pathologies like disc herniations.
doi:10.4076/1757-1626-2-6228
PMCID: PMC2769273  PMID: 19918563
25.  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

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