Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review

Soltani, Siamak; Nogaro, Marie-Caroline; Kieser, Sandra; Wyatt, Michael; Kieser, David

doi:10.1016/j.wneu.2019.05.050

Cited by 11 publications

(17 citation statements)

References 19 publications

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“…We herein describe an unusual case of SEH spanning over 24 vertebras in a 36-year-old woman with RA that developed severe neck pain and headache while performing a Valsalva maneuver during vaginal delivery. The average size of an SSEH extends across 3.9 levels [6], making this case rare. According to the literature, a key clinical feature in many SSEH cases is well-localized back pain, often following minimal physical activity [10].…”

Section: Discussionmentioning

confidence: 99%

“…During pregnancy, epidural venous pressure is increased due to an elevation of the intraabdominal pressure caused by the hypertrophic uterus, and a direct compression of the vena cava [27]. Those two physiological conditions divert a portion of the venous return from the lower extremities and pelvic region into the vertebral venous system, resulting in a higher blood volume in the extradural venous plexus predisposing to dilation and rupture of the epidural vessels [6]. The epidural veins lack valves, implying that elevated venous pressure in the epidural space during pregnancy may increase the risk for SSEH, especially during straining, coughing, or strenuous efforts such as a Valsalva maneuver [4,7].…”

Section: Discussionmentioning

confidence: 99%

“…Pregnancy is an independent risk factor [1]. The pathophysiology of SSEH is not conclusive and some data suggest that the source of bleeding is of venous origin [3][4][5][6], whereas other data suggests an arterial source [7]. Autoimmune or inflammatory disorders have also been described in the literature to be rare sources of hemorrhage in the spinal canal [1,8,9].…”

Section: Introductionmentioning

confidence: 99%

“…Non-specific neck or back pain is considered to be the earliest sign of SEH, though painless presentations of SEH have been described [3]. In a systematic review by Soltani et al in 2019, all 16 patients with SEH included in the review presented with symptoms of back or neck pain [6]. The hemorrhage in the extradural space may lead to spinal cord or nerve root compression that may potentially cause neurological deficits or even death.…”

Section: Introductionmentioning

confidence: 99%

“…Pregnancy results in an increased blood volume and increased pressure on the vascular walls which may lead to rupturing of vessels and subsequent SSEH, especially if vascular pathology is present. Because pregnancy is considered a hypercoagulable state (with hypercoagulability persisting through the first 2 weeks post-delivery), in the absence of predisposing factors, the incidence of SSEH is extremely low in this patient population [6]. Pre-eclampsia has been reported in a few cases of SSEH; however, it has not been identified as an individual risk factor [7].…”

Section: Introductionmentioning

confidence: 99%

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Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

Bäck

Åkerstedt

2022

SN Compr. Clin. Med.

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Spinal epidural hematomas (SEH) are a rare hemorrhagic event occurring after trauma, epidural anesthesia, or operative inventions. However, in 40–50% of cases, they occur spontaneously. Spontaneous spinal epidural hematomas (SSEH) are rare in occurrence with an estimated incidence of 1 case per million annually. Pregnancy is an independent risk factor. Sudden neck or back pain, often in combination with a rapid onset of neurological symptoms, is the most common presentation of SEH (1). A 36-year-old Caucasian female with rheumatoid arthritis (RA) presented to the emergency department approximately 48 h after an uncomplicated vaginal delivery. She sought medical attention due to constant headaches and neck pain that started during active labor. An MRI of the spine revealed an extensive SEH spreading from C1 to L5. The patient was without neurological symptoms or deficits and was successfully treated conservatively without any sequelae. Even though the definitive cause of this case of SEH will remain unknown, several possible synergistic mechanisms have been identified. These include female gender, full-term pregnancy, physical activity with increased intraabdominal pressure (i.e., Valsalva maneuver), systemic administration of platelet aggregation inhibitor (PAI), and iatrogenic manipulation such as spinal epidural anesthesia. Even though autoimmune and inflammatory disorders have been described in the literature to be rare sources of hemorrhage in the spinal canal, it is unclear whether the patient’s RA should be regarded as an individual risk factor. Key Facts Spinal epidural hematomas are a rare hemorrhagic event characterized by an accumulation of blood between the vertebrae and the dura of the spinal canal, and can be a clinical challenge to diagnose due to the insidious presentation, with symptoms ranging from asymptomatic to non-specific head or neck pain, or neurological deficits. The etiology of spontaneous spinal epidural hematomas remains largely unknown, although there are many predisposing factors, including vascular malformation, anticoagulation therapy, trauma, iatrogenic manipulations, and hypertension. The differential diagnosis to spinal epidural hematomas are several, e.g., meningitis, migraine, subarachnoid or intracranial hemorrhage, pituitary apoplexy, venous sinus thrombosis, and thrombosis, and radiological examination is key to diagnose and map the distribution of the hemorrhage.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

Bäck

Åkerstedt

2022

SN Compr. Clin. Med.

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An unusual presentation of spontaneous spinal epidural hematoma

2023

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We report a rare case of spontaneous spinal epidural hematoma. Various presentations may occur, most commonly including neck pain, interscapular pain, radicular pain, and paralysis. This condition is frequently associated with paralysis and long‐term disability. This case is unique because it presented with right hand cyanosis, in addition to pain. A 69‐year‐old Caucasian female presented with cyanosis of the right hand, and severe right upper extremity pain which awakened her approximately 11 hours earlier. The pain was exacerbated on extending her head. The patient further reported bilateral shoulder pain and interscapular pain. She reported no motor weakness or paralysis. She denied any history of trauma. The patient was taking aspirin 81 mg/d for the past 2 months. Physical examination revealed cyanosis of the digits of the right hand as well as mildly diminished right biceps reflex and right grip strength. No edema or rashes were noted. Skin was warm and dry. Pulses were +2 in all extremities. Vital signs were within normal limits. The remainder of the physical examination was unremarkable. Magnetic resonance imaging of the cervical/thoracic spine revealed a right posterior–lateral epidural hematoma extending from the 3rd cervical level to the 1st thoracic level of the spinal cord. There was also evidence of cord compression at the 4th‐5th and 5th‐6th cervical levels. Given the potential for significant complications, clinicians should maintain a high index of suspicion for spinal epidural hematoma, particularly in those patients taking anticoagulation. Symptoms, including extremity cyanosis, pain, and paralysis all are suggestive of the diagnosis.

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Low Back Pain and Sciatica in Pregnancy

Goldstein

2023

Neurological Disorders in Pregnancy

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Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review

Cited by 11 publications

References 19 publications

Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

Extensive Spinal Epidural Hematoma as the Cause of Postpartum Headache and Neck Pain After Epidural Anesthesia: a Case-Based Report

An unusual presentation of spontaneous spinal epidural hematoma

Low Back Pain and Sciatica in Pregnancy

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