Acute Spinal Epidural Hematoma, Clinical and Etiopathogenic Diagnostic Difficulties – Case Presentation and Synthesis of the Literature

Abstract

Introduction: Epidural hematoma has a double anatomopathological topography: intracranial and/ or spinal. Its etiology is complex: post-traumatic (spinal trauma, or lumbar puncture), iatrogenic (secondary to an inadequate anticoagulation or antiplatelet treatment), congenital or acquired disorders of coagulation (leukemia, hepatic cirrhosis), secondary to intense Valsalva maneuvers (e.g. during labor, or an intense physical effort), and idiopathic. The purpose of this article is to present a clinical case of acute spinal epidural hematoma (SEDH) with atypical clinical picture and a puzzled pathophysiological mechanism, and also a brief review of the relevant literature. Case presentation: An 80-years-old male patient, with locomotor disability (bilateral congenital foot deformity), and multiple cardiovascular comorbidities (chronic atrial fibrillation (AF), dilated cardiomyopathy and contractile dysfunction (chronic heart failure, with left ventricle ejection fraction 40 %), chronically anticoagulated with a vitamin K antagonist (acenocumarol). The elderly submitted a body-level fall without cranial trauma, event followed by a short loss of consciousness (without convulsions or sphincter relaxation). He suffered a low-energy cervical fracture (C7 vertebral injury) and a posterolateral acute SEDH at C3-Th2 vertebral levels. Decompressive hemilaminectomy at the C4-Th2 levels and evacuation of the SEDH, was performed during the early sub-acute phase. The patient was transferred in our rehabilitation clinic as C4 AIS-C tetraplegia (global motor score 50/100), neurogenic bladder and bowel, with post surgical wound dehiscence (healed per secundam). The subject had a favorable neurological evolution and was discharged as C7 AIS-D tetraplegia (global motor score 81/100). Discussion: The case particularity consists in a puzzled etiopathogenetic mechanisms and difficulty to accurately indicate the chronological chain of events generating the acute SEDH. An overdosed anticoagulant therapy might be incriminated as an iatrogenic cause for a "spontaneous" SEDH, but most probably its etiology is complex, probably traumatic, consequence of the cervical spine fracture due the low-intensity biomechanical impact. The complex predisposing circumstances to accidental fall in our elderly patient were due to the: -impaired, unstable locomotor function, secondary to his bilateral congenital clubfoot deformity / disability -chronic AF, contractile dysfunction and hypodiastolic phenomena, with cardiogenic syncope and global brain ischemia or transient ischemic cerebral attack. Despite the good immediate outcomes, his future functional prognosis might be poor, due to the advanced age, severe cardiovascular pathology and the complex disturbances of the neuro-myo-artro-kinetic apparatus (major impediments of the somatic / body functions and structure). This health-related condition had severe repercussions on the subject`s activity (related to tasks and basic activities of daily living) and participation, affecting the outcome of rehabilitat...

Spontaneous spinal epidural hematoma masquerading as atypical abdominal pain in a child

“…The mainstream view on the treatment of intraspinal hemorrhage is that surgical treatment should be actively performed after the diagnosis is clearly established, [ 12 , 13 ] and the operation should be performed within 72 hours after the onset of bleeding. [ 6 ] Although there are reports of conservative treatment, [ 2 , 14 ] incomplete hematoma absorption may occur secondary to spinal canal stenosis or affect spinal cord recovery. Postoperative prognosis is related to the progress of the patient's disease course, degree of spinal cord compression, timing of surgery, and patient's age.…”

“…The incidence of the disease is very low (1/100,000 persons), [ 1 ] accounting for 0.3% to 0.9% of all spinal cord injuries. [ 2 ] The disease has characteristics of acute onset, severe symptoms, and high disability rate. Spontaneous intraspinal hemorrhage mainly occurs in adults older than 40 years.…”