Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture

Abstract

We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case.

Can tranexamic acid reduce blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting

“…Although occurrences of postoperative spinal hematoma formation requiring emergency surgery are rare, it is nevertheless important to control perioperative bleeding to decrease its incidence. [ 7 – 9 ]…”

Ultra-delayed lumbar surgical wound hematoma

“…The symptoms of acute spinal epidural hematoma, as described in the medical literature, are sudden onset of severe pain along the spinal column lasting from a few minutes to a few hours, possibly with focal or evolving neurological symptoms such as flaccid paralysis or loss of sphincter control. [1417] Occasionally, there is transient improvement in the neurology. [8] Thus, acute spinal pain in a patient on anticoagulants should raise the suspicion of spinal epidural hematoma even before any neurological symptoms appear.…”

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored

“…[2,6,17] Major predisposing factors for pSEH included; perioperative/postoperative coagulation disorders, multilevel spinal surgery, prior spine surgery, and intraoperative cerebrospinal fluid leaks (CSF) [Tables 1 and 3]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The times to onset of symptomatic postoperative pSEH following all-level spine surgery ranged from an average of 2.7 postoperative hours, [1] to less than 24, [2] to between 24-48 postoperative hrs. [5] [Tables 1-4].…”

“…[4] The most critical factors to limit/avert permanent neurological sequelae of pSEH included; early recognition of new postoperative neurological deficits, obtaining immediate magnetic resonance imaging (MR) studies, and performing emergency spine surgery where indicated [Tables 1-4]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Incidence of pSEH e incidence of symptomatic postoperative spinal epidural hematomas (pSEH) involving all spinal levels ranged in 7 studies from 0.1% to 1%, [1,2,4,8,9,15,16] in 5 series from <1% to 2.9%, [11,12,15,17,18] and in 3 series between 3%-4.46% (i.e., the 1 of 10 patients with a 10% incidence of pSEH was considered an outlier) [2,6,17] [Tables 1 and 2]. [1][2][3][4][5][6][7][8][9][10]…”