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1.  Spontaneous and idiopathic chronic spinal epidural hematoma: two case reports and review of the literature 
European Spine Journal  2009;18(11):1555-1561.
Spinal epidural hematoma (SEH) represents the most frequent entity of acute or chronic spinal bleeding. Based upon pathogenesis, SEH can be classified as idiopathic, spontaneous, and secondary. The idiopathic forms are considered not to be attributed to any specific risk factors. Spontaneous SEH, accounting for 0.3–0.9% of all spinal epidural space occupying lesions, instead is associated with risk factors (such as substantial soft trauma or coagulation abnormalities). The chronic form, as our literature review revealed, is the rarest and its most frequent location is the lumbar spine. The pathophysiology of spontaneous and idiopathic SEH is still under debate: There are only a few reports in literature of chronically evolving SEH with progressively increasing pain and neurological impairment. Magnetic resonance imaging may be inconclusive for differential diagnosis. Here, we present two cases of lumbar chronic SEH with slow, progressive, and persistent lumbar radicular impairment. The first patient reported a minor trauma with slight back contusion and thus was classified as spontaneous SEH. In the second case not even a minor trauma was involved, so we considered it to be idiopathic SEH. In both cases preoperative blood and coagulation tests were normal and we did not find any other or co-factors in the patients’ clinical histories. MR imaging showed uncertain spinal canal obstructing lesions at L3 and L4 level in both cases. Surgical treatment allowed a correct diagnosis and resulted in full clinical and neuroradiological recovery after 1 year follow-up. Our aim is to discuss pathogenesis, clinical and radiological features, differential diagnosis and treatment options, on the background of relevant literature review.
PMCID: PMC2899401  PMID: 19859747
Spontaneous; Idiopathic; Chronic; Hematoma; Epidural; Spinal
2.  Case Report: Cauda Equina Syndrome Associated With an Interspinous Device 
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.
PMCID: PMC3348300  PMID: 21870210
3.  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.
PMCID: PMC2688151  PMID: 16807981
Clinical outcome; risk factor; postoperative; spinal epidural hematoma; spine surgery
4.  Spontaneous epidural hematoma of the spine associated with oral anticoagulants: 3 Case Studies 
•Spontaneous epidural hematoma of the spine (SEHS) is an extremely rare entity.•Early diagnosis and treatment showed to have the best outcome.•SESH should be suspected in every acute medullary syndrome with spinal pain, motor and/or sensory deficit.
Spontaneous epidural hematoma of the spine (SEHS) is an extremely rare entity. Patients known to have thrombophilia or on anticoagulant drugs are the most affected. It is generally caused by a rupture of the postero-internal vertebral venous plexus secondary to minor barotrauma such as cough, peridural catheter insertion...
Early diagnosis and treatment showed to have the best outcome.
Cases report
We report 3 cases of spontaneous epidural hematoma in patients treated by acenocoumarol, which occurred without any provocative factor. All 3 patients were treated with decompressive laminectomy.
We described the MRI findings and discussed the spontaneity of the entity. Our present case studies and the review of the literature showed that early diagnosis and management of SEHS can lead to improvement of the neurological state and avoid definitive motor and sensitive deficit.
This rare entity should be suspected in every acute medullary syndrome with spinal pain, motor and/or sensory deficit. In order to decrease the sequelae, neurologically unstable patients should benefit from early diagnosis and urgent surgical decompression.
PMCID: PMC4529632  PMID: 26074484
Spontaneous epidural hematoma of the spine; Oral anticoagulants; Acenocoumarol
5.  Infected epidural hematoma of the lumbar spine associated with invasive pneumococcal disease 
Spinal epidural abscess (SEA) and spinal epidural hematoma (SEH) are neurologic emergencies with distinct etiologies and treatment. Despite similarities on magnetic resonance imaging (MRI), their differentiation is usually possible with meticulous history taking and neurologic examinations. We report an unusual case of SEA that developed from preceding SEH, posing a diagnostic challenge to physicians. A 65-year-old diabetic man suddenly experienced back pain and weakness of both legs when he lifted heavy luggage. He was afebrile, and his laboratory tests were mostly unremarkable. Spinal MRI consisting of T1-weighted, T2-weighted, and fat-suppressed T2-weighted images revealed an epidural mass over the L2-L4 spinous process. He was diagnosed with SEH based on his symptoms and MRI findings, and was treated conservatively using steroid pulse therapy. Despite initial improvement, he suddenly developed into septic shock and coma on the 10th hospital day, and died shortly thereafter. An autopsy revealed massive pus accumulation in the lumbar epidural space and brain, and a postmortem diagnosis of infected SEH associated with invasive pneumococcal disease was established. Serial MRI studies, including diffusion-weighted and/or gadolinium-enhanced T1-weighted images are warranted in patients with a presumed diagnosis of SEH receiving steroid therapy to detect such infectious transformation.
PMCID: PMC4352647  PMID: 25767594
Invasive pneumococcal disease; magnetic resonance imaging; spinal epidural abscess; spinal epidural hematoma
6.  Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report 
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.
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.
PMCID: PMC3160384  PMID: 21794133
7.  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.
PMCID: PMC3249578  PMID: 22220233
Analgesia; Epidural; Hematoma; Postoperative complications; Spinal
8.  An Unusual Case of a Large Hematorrachis Associated with Multi-Level Osteoporotic Vertebral Compression Fractures; a Case Report 
Spinal epidural haemorrhage may present as back pain associated with radicular symptoms and can be a catastrophic clinical scenario with progression to paraplegia or even sudden death. Being a rare entity, it needs a high index of clinical suspicion to diagnose it. Fractures have been documented as a cause of hematorrachis but such hematomas only extend to one or two vertebral segments. Large epidural hematomas are usually associated with conditions like bleeding diathesis, arterio-venous malformations, plasma cell myeloma, and non-Hodgkin’s lymphoma. Surgical management with immediate evacuation of the hematoma is the usual line of management in patients with neurological deficits. Though rare, monitored and careful conservative management can lead to recovery of neurological symptoms and resolution of the hematoma. We report a case of a very large post traumatic epidural hematorrchis extending to 11 vertebral segments from D3 to L1 vertebral bodies, who had a gradual spontaneous recovery.
PMCID: PMC4468628  PMID: 26110182
Compression fracture; Epidural hematoma; Hematorrachis
Nagoya Journal of Medical Science  2014;76(1-2):195-201.
Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology.
PMCID: PMC4345727  PMID: 25130006
chronic lumbar epidural hematoma; spontaneous spinal epidural hematoma; scalloping; MRI findings
10.  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.
PMCID: PMC2899765  PMID: 19956984
Cervical spine; Clinical outcome; Endoscopic surgery; Laminoplasty; Myelopathy
11.  Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine 
European Spine Journal  2006;16(Suppl 3):326-331.
Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression.
PMCID: PMC2148084  PMID: 17053943
Vertebroplasty; Polymethylmethacrylate; Epidural extravasations; Thoracic myelopathy; Surgical removal
12.  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.
PMCID: PMC2740261  PMID: 19830087
13.  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.
PMCID: PMC2966734  PMID: 21082060
Spinal epidural hematoma; Pain control procedure; Surgical evacuation
14.  Spontaneous cervical epidural hematoma of idiopathic etiology: Case report and review of literature 
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.
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.
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.
PMCID: PMC3304555  PMID: 22333537
Tetraparesis; Tetraplegia; Paralysis; Myelopathy; Laminectomy; Neurologic manifestations; Progressive; Spinal cord compression; Cervical; Hematoma; Idiopathic spontaneous spinal epidural hematoma
15.  Solitary spinal epidural cavernous angioma: report of nine surgically treated cases and review of the literature 
European Spine Journal  2012;22(3):542-547.
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.
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.
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.
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.
PMCID: PMC3585645  PMID: 23053760
Cavernous angioma; Magnetic resonance imaging; Spinal epidural cavernoma; Spinal epidural lesion
16.  Hemiparesis Caused by Cervical Spontaneous Spinal Epidural Hematoma: A Report of 3 Cases 
Advances in Orthopedics  2011;2011:516382.
We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.
PMCID: PMC3170783  PMID: 21991415
17.  Misdiagnosis of spontaneous cervical epidural haemorrhage 
European Spine Journal  2008;18(Suppl 2):210-212.
Spontaneous spinal epidural haemorrhage is a rare condition. The initial clinical manifestations are variable. Nonetheless, most spinal cord lesions result in paraparesis or quadriparesis, but not hemi-paresis, if motor function is involved. We report on a 69-year-old man who presented initially with right-side limb weakness. He was initially misdiagnosed at emergency room with a cerebral stroke and treated inappropriately with heparin. One day after admission, correct diagnosis of acute spinal epidural haematoma was based on the repeated neurological examination and cervical magnetic resonance imaging study. The patient underwent emergency surgical decompression and hematoma removal. The pathogenesis of the haematoma could have been due to hypertension, increased abdominal pressure and anticoagulant therapy. We emphasize that patients with hemi-paresis on initial presentation could have an acute spinal epidural haemorrhage. We also draw the misdiagnosis to the attention of the reader because early recognition of spontaneous spinal epidural haematoma is very important for prompt and appropriate treatment to improve the overall prognosis.
PMCID: PMC2899547  PMID: 19005691
Spontaneous spinal epidural haemorrhage; Hemi-paresis; Cerebrovascular disease
18.  Thunderclap headache as a presentation of spontaneous spinal epidural hematoma with spontaneous recovery 
Spontaneous spinal epidural hematoma (SSEH) is a rare spinal cord compression disorder. Thunderclap headache mimicking subarachnoid hemorrhage as an initial manifestation of this disorder has been scarcely reported. Moreover, the neurological outcome of conservative treatment is satisfactory only in some clinical settings. The unusual presentation and mechanisms for spontaneous recovery of SSEH are discussed.
To report a case of SSEH that presented with acute severe headache that mimicked subarachnoid hemorrhage. After a period of neurological deficit, spontaneous improvement was seen, which progressed to full recovery without neurosurgical intervention.
A 62-year-old man presented with acute occipital headache and neck stiffness for which subarachnoid hemorrhage was initially suspected. An emergency computed tomographic brain scan and cerebrospinal fluid analysis excluded subarachnoid hemorrhage. Later, he developed acute paraparesis, hypoesthesia up to the fourth thoracic dermatomal level (T4) as well as bowel and bladder dysfunction. The magnetic resonance imaging eventually revealed spinal epidural hematoma, located anterior to C7 through T4 spinal level. He had no previous history of spinal injury, systemic, and hematological disorders. The neurological recovery began 20 hours after the onset and continued until complete recovery, 4 months after the onset without neurosurgical intervention.
SSEH could sometimes imitate subarachnoid hemorrhages when it located in the cervical region. Spontaneous recovery of SSEH without surgical intervention might be possible in cases with continuing neurological recovery, although the recovery began much later in the clinical course.
PMCID: PMC3831335  PMID: 24090118
Headache; Spontaneous spinal epidural hematoma; Subarachnoid hemorrhage; Paraparesis
19.  Principles of management of osteometabolic disorders affecting the aging spine 
European Spine Journal  2003;12(Suppl 2):S113-S131.
Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12–24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.
PMCID: PMC3591829  PMID: 14505119
Osteoporosis; Fractures; Neurological deficit; Deformity; Paget's disease; Back pain; Spinal stenosis; Myelopathy; Treatment
20.  Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature 
Korean Journal of Spine  2011;8(4):272-282.
The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits.
Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases.
Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients.
We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.
PMCID: PMC4461739  PMID: 26064145
Spinal epidural hematoma; Back pain; Neurological deficits; MRI
21.  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.
PMCID: PMC3243847  PMID: 22200026
Idiopathic hypertrophic spinal pachymeningitis; Spinal cord compression; Chronic nonspecific inflammation; Dural thickening
22.  Sudden onset of paraplegia caused by hemorrhagic spinal epidural angiolipoma. A case report 
European Spine Journal  2008;17(Suppl 2):296-298.
Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating an extradural hematoma. The patient was admitted with sudden non-traumatic hyperacute paraplegia during a prolonged walk. Neurologic examination showed sensory loss below T6 and bladder disturbances. Spinal MRI revealed a non-enhanced heterogeneous thoracic epidural lesion, extending from T2 to T3. A bilateral T2–T4 laminectomy was performed to achieve resection of a lipomatous tumor containing area of spontaneous hemorrhage. The postoperative course was uneventful with complete neurologic recovery. Histologic examination revealed the tumor as an angiolipoma. Because the prognosis after rapid surgical management of this lesion is favorable, the diagnosis of spinal angiolipoma with bleeding should be considered in the differential diagnosis of hyperacute spinal cord compression.
PMCID: PMC2525899  PMID: 18228054
Angiolipoma; Epidural spinal tumor; Spinal cord compression; Spinal epidural hematoma
23.  Haemophilia A presenting as spontaneous spinal epidural haematoma in a 3-month-old infant 
BMJ Case Reports  2010;2010:bcr0520102997.
Spinal epidural haematoma (SEH) is a rare complication of haemophilia. A 3-month-old boy presenting with non-traumatic acute onset quadriparesis was found to have SEH on MRI scan. On further investigations, diagnosis of severe haemophilia A was confirmed. He responded well to conservative treatment with replacement of factor VIII without any need for surgical decompression. Neurological recovery was complete. We believe this is the youngest reported case of haemophilia presenting with spontaneous SEH. Another peculiarity of this case is absence of excessive bleeding due to forceps and vacuum application, circumcision and intramuscular injection, even in the presence of severe haemophilia. This case calls attention to the clinical features, radiological appearances and management options of this rare complication of SEH in people with haemophilia.
PMCID: PMC3027406  PMID: 22791488
24.  Cervical Epidural Hematoma after Chiropractic Spinal Manipulation Therapy in a Patient with an Undiagnosed Cervical Spinal Arteriovenous Malformation 
Cureus  null;7(8):e307.
Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.
PMCID: PMC4578713  PMID: 26430581
spinal epidural hematoma; chiropractic manipulation; spinal arteriovenous malformation
25.  Cervicothoracic Spinal Epidural Hematoma after Anterior Cervical Spinal Surgery 
The purpose of this case report is to describe a rare case of a cervicothoracic spinal epidural hematoma (SEH) after anterior cervical spine surgery. A 60-year-old man complained of severe neck and arm pain 4 hours after anterior cervical discectomy and fusion at the C5-6 level. Magnetic resonance imaging revealed a postoperative SEH extending from C1 to T4. Direct hemostasis and drainage of loculated hematoma at the C5-6 level completely improved the patient's condition. When a patient complains of severe neck and/or arm pain after anterior cervical spinal surgery, though rare, the possibility of a postoperative SEH extending to non-decompressed, adjacent levels should be considered as with our case.
PMCID: PMC3053552  PMID: 21430984
Cervical spine; Complication; Hematoma

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