Epidural Hematoma Presenting with Severe Neck Pain without Neurological Deficit - A Late Complication of Posterior Cervical Spine Surgery: Presentation of Three Unusual Cases

Abstract

Postoperative epidural hematoma (EDH) usually present with neurological deficit. Massive EDH presenting with only severe pain without neurological deficit are rare. Atypical presentations of postoperative EDHs may lead to delayed diagnosis and treatment. We present three such cases after posterior cervical spine surgery. Three patients presented with severe neck pain and spasms without motor deficits several days after posterior cervical decompressive procedures. Imaging studies identified compressive EDHs at the surgical site with severe compression of the spinal cord. All were treated with emergent decompression, with resulting improvement of symptoms and pain relief without further neurological sequelae. In conclusion, postoperative EDHs after posterior cervical spine surgery may result in minimal neurological deficit. Our report reminds surgeons to keep this possibility in mind when patients complain of unusually severe neck pain and spasms after posterior cervical spine surgery.

A New Grading of Epidural Hematoma or Scar Formation after Posterior Cervical Spine Surgery: Evaluation of Perioperative Related Factors, Distributions, and Clinical Outcomes after Surgery

“…Most hematomas often result in a sudden inability to move the extremities just after surgeries 2,6) . Yet, a case report presenting three patients with severe neck pain on physical examination showed a slow-growing postoperative EH despite normal motor function 4) . In any case, serious complications require the urgent surgical removal of EHs.…”

“…Several reports have described symptomatic postoperative EH after posterior cervical spine surgery [2][3][4][5][6] . Recently, Schroeder et al investigated retrospectively a total of 16,582 cervical spine surgeries (8,887 anterior procedures and 7,695 posterior procedures) across multiple centers, and reported fewer EHs in anterior procedures (5.63 per 10,000 anterior cases) than in posterior procedures (13.00 per 10,000 posterior cases) 20) .…”

“…A previous study identified the risk factors of postoperative retropharyngeal hematoma as (1) diffuse idiopathic skeletal hyperostosis, (2) ossi-fication of the posterior longitudinal ligament (OPLL), (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels 1) . On the contrary, after posterior cervical spine surgery, postoperative epidural hematoma (EH) can cause various symptoms including paralysis 2,3) and intolerable neck pain 4,5) , with urgent surgical removal of the hematoma sometimes needed 6) . It remains unclear what risk factors are associated with postoperative EH after posterior cervical spine surgery.…”

Delayed postoperative spinal epidural hematoma after anterior cervical discectomy and fusion: A case report

“…Some patients have atypical manifestations, presenting only slight and slowly aggravating neurological deficits but with no pain, especially for DPOSEH ( 16 , 19 ). A few cases have shown a gradual development of SEH after the operation, which may only manifest as neck pain and spasm without muscle strength reduction ( 14 ). Physical examination before the operation may indicate a suspected hematoma segment, which is helpful for rapid positioning and quick relief of compression during the operation.…”

“…A small artery rupture in the neck muscle was found during the second operation, which was considered to be related to constipation and intense activities after getting out of bed. Khan et al reported that DPOSEH occurred on the third and ninth days after posterior cervical spine surgery in two cases, which mainly manifested as neck pain and spasm, without muscle strength reduction, and both patients completely recovered after a second operation ( 14 ). Tomii et al reported a case of DPOSEH seven days after posterior cervical spine surgery, with a history of hypertension and poor perioperative blood pressure control.…”