Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma

Abstract

Objective.Spontaneous spinal epidural hematoma (SSEH) is an uncommon but serious condition with a high morbidity rate. Although SSEH is related to numerous risk factors, its etiology remains unclear. There is a paucity of data on its prognostic factors. We aim to evaluate prognostic factors for SSEH in the current study.Method.A retrospective study was performed on patients who were admitted for SSEH in three academic neurosurgical centers from Jan 2010 to June 2021. Clinical parameters, including clinical condition on admission, anticoagulants use, imaging modality, the timing and type of surgery performed, and outcomes, were collected. Prognostic factors were analyzed. The Frankel scale was used to assess the clinical condition.Results.A total of 105 patients with SSEH were retrieved from medical records, with a mean age of 51.3 years. Eighty three patients (79%) complained of acute onset of severe neck or back pain. Eighty two patients (78%) suffered from moderate to severe neurologic deficits (Frankel scale A-C). Anticoagulation usage was found in 20% of cases. Lower thoracic spine (p=0.046), use of anticoagulants (p=0.019), sphincter function disfunction (p=0.008), severe neurologic deficits at admission (p <0.001), and rapid deterioration (< 1 hour, p=0.004) were found to be associated with poor outcomes. Surgical decompression was performed in 74 (70%) cases. The univariate and multivariate analysis revealed that pre-operative severe neurologic deficits (p=0.005) and extended paraplegia time (>12 hours, p=0.004) were independent adverse prognostic factors. The univariate analysis revealed that lower thoracic spine location (p=0.08) and rapid progression (<6 hours, p=0.005) were correlated with poor prognosis, but the multivariate analysis failed to identify them as independent prognostic factors.Conclusion.Adverse prognostic factors for SSEH might include thoracic segment location, use of anticoagulation, severe neurologic deficits on admission, sphincter dysfunction, and rapid progression. Preoperative neurologic deficit and extended paraplegia time were strongly correlated with the prognosis in the subset of patients that underwent surgical decompression. Timely surgical decompression is recommended for patients with moderate/severe neurologic deficits or progressive neurological deterioration.

Two Patients with Spontaneous Spinal Epidural Hematoma Carrying a Good Prognosis without Surgical Operations

“…The anterior part of the internal vertebral venous plexus is thought to be hard to rupture compared with the posterior part because the anterior part clings to the posterior longitudinal ligaments [ 1 , 4 , 14 , 15 ]. Hematomas in our patients were located posteriorly to the spinal cord, which was consistent with the characteristics of SSEH [ 1 , 5 , 6 , 7 , 8 , 12 , 14 ] and was probably caused by the rupture of the internal vertebral venous plexus.…”

“…An increase in the intravenous pressure caused by Valsalva maneuvers may possibly cause the internal vertebral venous plexus to rupture [ 1 ]. The posterior part of the internal vertebral venous plexus is considered to be the most likely point of rupture in SSEH [ 1 , 5 , 6 , 7 , 8 , 12 , 14 ]. The anterior part of the internal vertebral venous plexus is thought to be hard to rupture compared with the posterior part because the anterior part clings to the posterior longitudinal ligaments [ 1 , 4 , 14 , 15 ].…”

“…Once diagnosed with SSEH, urgent surgical intervention has been indicated in principle [ 1 , 2 , 5 , 6 , 7 , 8 , 18 ] and recommended within 48 h after onset [ 1 , 2 , 8 ]. SSEH with three factors, i.e., (1) severe neurological deficit, (2) significant mass effect, and (3) worsened clinical manifestation, is indicative for surgical treatment [ 4 ].…”

“…Spontaneous spinal epidural hematoma (SSEH) is a rare disease that affects only 1 in 100,000 people per year [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. SSEH occurs predominantly in patients between the ages of 40 and 80 years, with a mean age of 71 years [ 10 ].…”

“…SSEH occurs predominantly in patients between the ages of 40 and 80 years, with a mean age of 71 years [ 10 ]. Men are slightly more frequently affected than women [ 1 , 5 , 7 ]. SSEH can produce devastating neurological deficits such as severe paraplegia and sphincter-rectal dysfunction [ 1 ], and this condition points to the formation of hematoma caused by the collection of blood within the epidural space of the spinal cord in the absence of traumatic or iatrogenic causes [ 1 , 2 , 3 , 4 , 5 , 6 , 10 , 11 , 12 , 13 , 14 ].…”