Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report

Spontaneous spinal epidural hematoma (SSEH) is a rare cause of back pain in the emergency department (estimated incidence of approximately 0.1 per 100,000 patients per year [1]) but one that carries high morbidity. The classic clinical presentation is acute onset of severe, often radiating, back pain followed by signs and symptoms of nerve root and/or spinal cord compression, which develops minutes to days later [2‐4]. The true etiology of SSEH remains unknown, but associations with some predisposing conditions, such as coagulopathies, blood dyscrasias and arteriovenous malformation, have been reported [5, 6]. Although there are occasional reports of nonoperative treatments, timely surgical extirpation of the epidural clot remains the standard management [7].

This article presents a previously healthy young man who was admitted to the emergency department with back pain and symptoms of spinal cord compression caused by SSEH, in whom prompt surgical treatment prevented definitive neurological sequelae.

SSEH is defined as accumulation of blood in the vertebral epidural space that has no obvious cause. It represents 40% of all spinal epidural hematomas [8, 9]. The pathogenesis is unclear but the bleeding is assumed to be of venous origin [6]. The valveless epidural venous plexus is particularly vulnerable to variations in pressure from the abdominal and thoracic cavities [6, 8]. Hematomas are usually located posterior to the spinal cord, which is consistent with the anatomical location of the venous plexus [9, 10]. In one large literature survey of case reports of spinal hematomas of any causes, Kreppel et al. [9] described that almost 75% of spinal hematomas are located posterior to the spinal cord. Ventral hematomas, as in our case, represented only 5% of all cases. Other authors have also described this posterior predominance [7, 10, 11].

SSEH occurs in all age groups, but most frequently after the fourth decade of life [10]. The most common localizations in adults are the cervicothoracic and thoracolumbar junctions [6]. The clinical presentation in most cases is the same as in our case, namely sudden-onset back pain followed by signs of nerve root or spinal cord compression. The symptoms of spinal cord compression may include ascending numbness, progressive paraplegia and/or loss of leg sensory function, and cauda-equina syndrome [1, 11]. However, owing to its rarity, the exact diagnosis of SSEH may be difficult in a timely manner. The differential diagnosis includes spinal abscess, tumor, ischemia, transverse myelitis and acute vertebral disc disease [6].

Since the results of operative decompression of the spinal cord depend on the duration of the symptoms, time lost during diagnostic procedures may have negative influences on the outcome [7, 9‐13]. Consequently, accurate neuroradiologic confirmation of the correct diagnosis is mandatory. In the past, lumbar myelography and computed tomography scanning were used for diagnosis. However, these techniques are nonspecific, may not provide the accurate length of the hematoma and may produce false-negative findings [11, 14]. Currently, spinal MRI has replaced these techniques as the initial diagnostic tool for SSEH. MRI is noninvasive, accurate and can demonstrate the localization and length of the hematoma as well as the effects on the spinal cord [1, 10, 11]. Furthermore, on T2-weighted images, hyperintense signals in the compressed spinal cord, suggesting intramedullary edema, may portend poor neurological recovery [10]. In our case, MRI provided detailed information about the magnitude, localization, dimension, limits and nature of the epidural mass. Although the compression of the spinal cord was significant (Figure 1C), there were no hyperintense signals on T2-weighted images of the spinal cord. This was correlated with a good postoperative recovery, in much the same way as described above [10].

The most relevant aspect of this case report is the early surgical management. This factor may have been the crucial determinant of the good neurologic outcome in our case. Many authors have already described that the speed of surgical intervention is correlated with better neurological and functional recovery [7‐12]. A time frame of less than 12 hours from the initial ictus seems to be the best therapeutic window [10‐12]. In our case, the patient underwent surgery at slightly more than 2 hours after the onset of the symptoms of spinal cord compression, and long before any neurological structural damage could be identified by MRI. Therefore, based in our case and the literature reviewed, we emphasize that SSEH is a neurosurgical emergency requiring immediate surgical intervention.

Another factor besides surgical timing that might affect the outcome is the patient's preoperative neurological status. Groen et al. [7] expertly reviewed the literature and reported 330 cases of SSEH. In their paper, postoperative recovery was correlated with sensorimotor impairment before surgery. Other authors described similar results in smaller case series [10, 12]. Of note, complete loss of sensorimotor function may be recovered after decompressive laminectomy [7, 13]. Other factors such as age, sex, and size and position of the hematoma were not correlated with the postoperative outcome [7]. Spinal cord infarction after decompressive laminectomy may also complicate the postoperative course and impair recovery [15].

In conclusion, although SSEH is rare in the emergency department, it is a critical diagnosis to consider in cases of sudden back pain with symptoms of spinal cord compression. Urgent spinal MRI is crucial for correct diagnosis, and decompressive surgical management with evacuation of the hematoma is imperative. Fast and solid clinical recognition and diagnosis combined with appropriate treatment may improve the neurological and functional outcomes.

Written informed consent was obtained from the patient's next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.