Extramedullary hematopoiesis (EMH) can occur in patients with thalassemia intermedia as a physiologic response to insufficient erythropoiesis to meet circulatory demands. Rarely, EMH involve the epidural space causing spinal cord compression. We describe a case of EMH in a 21-year-old man with β-thalassemia intermedia presenting with progressive low back pain, worsening paraparesis and sphincter disturbance. Magnetic resonance imaging (MRI) demonstrated spinal cord compression by EMH epidural mass lesions extending from T3 to T10 levels. An emergency multilevel decompressive laminectomy was performed with excision of the masses and complete rehabilitation of the patient.

Spontaneous spinal epidural hematoma is an increasingly recognized entity in clinical practice. MR is a valuable tool in diagnosis yet its chronological signal changes and different pattern of enhancement may impose a diagnostic difficulty. Other worrisome differential diagnostics with different management, prognoses represent the daily radiologist challenge. We present a case of pure lumbar radiculopathy caused by accidentally discovered spontaneous late sub-acute epidural hematoma and discuss the diagnostic differentials of lumbar spinal epidural mass lesions.