Spontaneous chronic epidural hematoma of the lumbar spine mimicking an extradural spine tumour

Fuster, Salvador; Castañeda, Santiago; Ferrer, Enrique; Wang, Jeffrey; Poblete, José

doi:10.1007/s00586-012-2402-0

Cited by 10 publications

(12 citation statements)

References 17 publications

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“…Spontaneous spinal epidural hematoma is a rare, but recognized, entity. The causes of spontaneous spinal epidural hematoma vary but may be higher in patients with bleeding disorders, therapy with anticoagulants following thrombolysis for MI and spinal arteriovenous malformation, chiropractic manipulation, diving, hypertension, Paget's disease, and ankylosing spondylitis (181,185,202,203,207,208,223,225,231,232,245,260,275,278,295,297,319,(343)(344)(345)(348)(349)(350)(351)(352)357,358,362,365,368,373,376,(378)(379)(380)(463)(464)(465)(466)(467)(468)(469)(470)(471)(472)(473)(474)…”

Section: Study/year Case Report Conclusion By the Study Authorsmentioning

confidence: 99%

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Atlantic

Manchikanti

Benyamin³

et al. 2013

Pain Phys

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Background: Interventional pain management is a specialty that utilizes invasive procedures to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving exogenous anticoagulants and antithrombotics. Even though the risk of major bleeding is very small, the consequences can be catastrophic. However, the role of antithrombotic therapy for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events is also crucial. Overall, there is a paucity of literature on the subject of bleeding risk in interventional pain management along with practice patterns and perioperative management of anticoagulant and anti-thrombotic therapy. Study Design: Best evidence synthesis. Objective: To critically appraise and synthesize the literature with assessment of the bleeding risk of interventional techniques including practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Methods: The available literature on the bleeding risk of interventional techniques and practice patterns and perioperative management of anticoagulant and antithrombotic therapy was reviewed. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through December 2012 and manual searches of the bibliographies of known primary and review articles. Results: There is good evidence for the risk of thromboembolic phenomenon in patients who discontinue antithrombotic therapy, spontaneous epidural hematomas occur with or without traumatic injury in patients with or without anticoagulant therapy associated with stressors such as chiropractic manipulation, diving, and anatomic abnormalities such as ankylosing spondylitis, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation may occur with interventional techniques when antithrombotic therapy is continued, the risk of thromboembolic phenomenon is higher than the risk of epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques, to continue phosphodiesterase inhibitors (dipyridamole [Persantine], cilostazol [Pletal], and Aggrenox [aspirin and dipyridamole]), and that anatomic conditions such as spondylosis, ankylosing spondylitis and spinal stenosis, and procedures involving the cervical spine; multiple attempts; and large bore needles increase the risk of epidural hematoma; and rapid assessment and surgical or nonsurgical intervention to manage patients with epidural hematoma can avoid permanent neurological complications. There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy clopidogrel (Plavix), ticlopidine (Ticlid), or prasugrel (Effient) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) to discontinue to avoid bleeding and epidural hematomas during interventional techniques and to continue to avoid cerebrovascular and cardiovascular thromboembolic events. Recommendations: The recommendations derived from the comprehensive assessment of the literature and guidelines are to continue NSAIDs and low dose aspirin, and phosphodiesterase inhibitors (dipyridamole, cilostazol, Aggrenox) during interventional techniques. However, the recommendations for discontinuation of antiplatelet therapy with platelet aggregation inhibitors (clopidogrel, ticlopidine, prasugrel) is variable with clinical judgment to continue or discontinue based on the patient’s condition, the planned procedure, risk factors, and desires, and the cardiologist’s opinion. Low molecular weight heparin (LMWH) or unfractionated heparin may be discontinued 12 hours prior to performing interventional techniques. Warfarin should be discontinued or international normalized ratio (INR) be normalized to 1.4 or less for high risk procedures and 2 or less for low risk procedures based on risk factors. It is also recommended to discontinue Pradaxa for 24 hours for paravertebral interventional techniques in 2 to 4 days for epidural interventions in patients with normal renal function and for longer periods of time in patients with renal impairment, and to discontinue rivaroxaban for 24 hours prior to performing interventional techniques. Limitations: The paucity of the literature. Conclusion: Based on the available literature including guidelines, the recommendations in patients with antithrombotic therapy for therapy prior to interventional techniques are provided. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions

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Section: Study/year Case Report Conclusion By the Study Authorsmentioning

confidence: 99%

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Atlantic

Manchikanti

Benyamin³

et al. 2013

Pain Phys

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“…Spinal epidural hematomas (SEHs) are uncommon clinical entities, accounting for only 0.3–0.9% of all space-occupying lesions in the spinal canal [ 1 , 2 ]. Chronic SEHs are most frequently located in the lumbar spine [ 1 , 3 , 4 ] and are very rare, accounting for 0.1% of all SEHs [ 5 ]. A preoperative imaging diagnosis of chronic SEHs is often not possible, as the results of computed tomography and magnetic resonance imaging (MRI) may be inconclusive [ 1 , 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…Chronic SEHs with vertebral scalloping are extremely rare. To the best of our knowledge, only two cases have previously been reported [ 2 , 5 ]. Herein, we report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping and acute cauda equina syndrome, which was initially misdiagnosed as an intraspinal tumor.…”

Section: Introductionmentioning

confidence: 99%

Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report

Fukatsu

Ogihara

Imada

et al. 2022

BMC Musculoskelet Disord

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Background Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor. Case presentation A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved. Conclusions The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping.

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“…The chronic hematomas, on the other hand produce some neurological symptoms (parestesie, claudication, etc.). For this reason even if rare spinal extradural chronic hematoma has to be considered in the differential diagnosis of nerve roots pain [4] , [5] , [7] . It is important to collect data from patient history (i.e.…”

mentioning

confidence: 99%

“…previous trauma) and to perform a clinical evaluation and then an MR spinal exam. The common site of a spontaneous chronic hematoma in the few articles reported in the literature is the thoracolumbar region [1] , [2] , [4] , [5] , [8] . Hematoma seems to originate from the rupture of Batson's plexus in the epidural space due to changes in venous pressure generally after trauma.…”

mentioning

confidence: 99%

Chronic extradural spinal hematoma after previous trauma

Gaeta

Capobianco

2015

European Journal of Radiology Open

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Spontaneous chronic epidural hematoma of the lumbar spine mimicking an extradural spine tumour

Cited by 10 publications

References 17 publications

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report

Chronic extradural spinal hematoma after previous trauma

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