A rare diagnosis in emergency department. Spontaneous spinal epidural hematoma
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Tarih
2008
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
W.B. Saunders
Erişim Hakkı
info:eu-repo/semantics/closedAccess
Özet
We report a case of a 32-year-old man who presented to the emergency department (ED) with a sudden onset of paraplegia due to spontaneous spinal epidural hematoma. Although the patient had a poor neurological condition on presentation, he was successfully operated and discharged without any neurological sequel. Spontaneous spinal epidural hematoma is a rarely seen clinical entity, especially in the ED. Magnetic resonance imaging is the best choice for early diagnosis, and urgent surgical decompression is essential to prevent serious neurological deficits. A 32-year-old previously healthy man presented to the emergency department with a complaint of sudden onset of numbness and weakness of the lower extremity. He had been having back pain during 1 week before presentation, and it was gradually worsening. There was no medical history of any recent trauma or illness, and he was on no medication. On presentation, his vital signs were stable. He was in apparent distress because of back pain. Physical examination revealed paraplegia and bilateral lower extremity anesthesia below the T3 dermatome. Deep tendon reflexes were absent on both lower extremities. The rest of physical examination including peripheral pulses and anal sphincter tone was normal. Complete blood count, electrolytes, coagulation, and kidney and liver function tests were normal except that white blood cell count was 13 500/µL, creatine kinase was 447 U/L (range, 24-195 U/L), and myoglobin was 128 ng/mL (range, <70 ng/mL). Thoracic and abdominal contrast-enhanced computed tomography was performed with a suspicion of aortic dissection, and it revealed normal aortic anatomy. Afterward, he underwent spinal magnetic resonance imaging (MRI). Magnetic resonance imaging demonstrated spinal epidural hematoma at the level of C7-T3 causing spinal cord compression (Fig. 1). Intravenous pulse prednisolone (bolus of 30 mg/kg and maintenance of 5.4 mg/kg per hour) therapy was initiated, and he was admitted to the neurosurgery ward. He was successfully operated the following day and discharged without any neurological sequel after 5 days of admission. Spontaneous spinal epidural hematoma (SSEH) is a relatively rare but important neurological emergency. The incidence is 0.1 patients per 100 000 populations [1]. It presents in all ages, and most cases occur after the fourth or fifth decade [2]. The common symptom is preceding neck or back pain, followed by sudden onset of neurological deficits [3]. The initial neck or back pain is sometimes vague and cannot be early diagnosed until the following cord compression and neurological deficits present. Although sensory and motor deficits are usually bilateral (paraplegia or quadriplegia), unilateral involvement (hemiparesis or hemiplegia) or Brown-Sequard syndrome is also reported [4-6]. Urine retention or loss of sphincter tone frequently accompanies. If the hematoma extends above the upper cervical vertebra, respiratory failure may be observed [6]. The etiopathogenesis of spinal epidural hematoma is not clear, although many predisposing factors including abnormality of coagulation (hemophilia), vascular malformation (eg, spinal dural arteriovenous fistula and hemangioma), some drugs (eg, anticoagulant therapy, therapeutic thrombolysis, aspirin, clopidogrel, and cocaine abuse), trauma (vertebral fractures, postsurgical bleeding, and missile injuries), and iatrogenic manipulations (spinal/epidural injections) are suggested [3,7-11]. The duration between onset of symptoms and inciting event varies from minutes to months [11,12]. Spontaneous spinal epidural hematoma is defined as spontaneous collection of blood in spinal epidural space without any obvious causes. Idiopathic cases account for approximately 40% to 60% of all spinal epidural hematoma [3,13]. Straining-associated events such as bending, dancing, swimming, sneezing, coughing, vomiting, micturition, or heavy lifting may play a role in the development of SSEH [3,14]. Liu and colleagues [3] reported that SSEH is generally located (96%) in the dorsal aspect of the spinal epidural space in cervical (30%), thoracic (35%), and cervicothoracic (22%) levels. They also demonstrated a worse prognosis associated with the bigger size of hematoma, shorter progressive intervals between the initial onset and emergence of the obviously neurological deficits (<12 hours), and a poor neurological condition on presentation [3]. Epidural venous plexus have been considered the source of hemorrhage for SSEH by many authors. The bleeding from rupture of valveless venous plexus in the epidural spaces is possibly secondary to abrupt change in venous pressure after blunt trauma or straining. In addition, the rapidly deteriorating neurological deficits after initial back pain and quick formation of the hematoma also suggested the arterial origin of SSEH [15,16]. Acute or progressive painful paraparesis and/or paraparesis with sphincter dysfunction is a well-known indication for an emergency MRI. Magnetic resonance imaging is the most useful method for diagnosis of SSEH. Magnetic resonance imaging can evaluate the location, extent, and compressive effects of hemorrhage. The hematomas usually appear as a shuttle-shaped image on sagittal section and a crescent-shaped image on transverse section dorsal to the spinal cord on MRI. In the hyperacute phase, MRI demonstrates an isointense lesion on T1-weighted images and hyperintense lesion on T2-weighted images. In the late or subacute phase, the hemorrhage demonstrates a hyperintense lesion on T1- and T2-weighted images [17]. Although some cases of spontaneous recovery have been reported, the most appropriate treatment of SSEH is surgical decompression [18]. Laminectomy and evacuation of the hematoma is the most effective method for rapid decompression of the spinal cord. The best favorable outcome can be achieved if surgical decompression is performed within 12 hours of symptom onset [19]. Therefore, operation should be considered as soon as possible, unless the neurological deficits resolve in the earlier period. Our patient had no history of any trauma, recent medication, or iatrogenic manipulations. His coagulation tests including prothrombin time, activated partial thromboplastin time, and platelet counts were normal. Therefore, in our case, spontaneous spinal epidural hematoma was considered. Spontaneous spinal epidural hematoma was diagnosed using MRI, and he was operated on immediately. Early diagnosis and treatment were the major factors that contributed to the complete recovery of our patient. Spinal epidural hematomas can cause dramatic neurological deficits, which can be successfully reversed if diagnosed and treated without delay. Emergency physicians should be aware of spinal epidural hematoma in patients presenting with back pain and new-onset neurological deficits, and MRI as an appropriate diagnostic modality should be performed immediately. © 2008 Elsevier Inc. All rights reserved.
Açıklama
Anahtar Kelimeler
Kaynak
American Journal of Emergency Medicine
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Scopus Q Değeri
N/A
Cilt
26
Sayı
7
