Spontaneous Spinal Epidural Hematoma

Abstract

Spontaneous spinal epidural hematoma is a rare entity, which frequently remains undiagnosed. Without early treatment, permanent paralysis or even a rapid fatality can result. Spinal epidural hematoma must thus be considered a neurosurgical emergency just as ominous as its intracranial traumatic counterpart. Since Bain (3) published the first case in 1897, a total of 39 have been reported. Ver Brugghen (24) reviewed the first 7 cases in 1946 and emphasized the lack of information on this subject in the texts. He also recognized the value of prompt recognition of the condition. Kaplan and Denker (10) in 1949 summarized the previous literature and added 2 cases of their own. They felt that the spinal epidural bleeding was of venous origin and postulated rupture of a weakened vessel in a pre-existing abnormal epidural venous plexus as a basic pathologic process. They failed, however, to furnish any convincing evidence to support this premise. Another important paper on the subject, by Schultz and his co-workers, appeared in 1953 (21). These authors felt that the syndrome occurred mainly in adults and was frequently preceded by a history of trauma. More recently Lowrey (12) added 3 new cases, as well as 5 others which followed the publication of Schultz's article in 1953. Ainslie (1) reported 3 cases (2 of which had been previously reported by Schultz); all were in elderly hypertensive patients with no history of trauma or physical exertion. The most recent series is that of Lougheed and Hoffman (11). They added 6 new cases to the existing total of 26. Only one reference to this syndrome can be found in the radiologic literature (4). Recently, at our hospital, the author had the opportunity of observing 5 patients with spontaneous spinal epidural hematoma. The following case reports and discussion are presented to acquaint the radiologist, neurologist, and neurosurgeon with this lesion, and to re-emphasize its importance. Case Reports Case I: E. P. R., a 62-year-old white woman, was admitted to the hospital on July 18, 1960. On the day prior to admission, she experienced a sudden incomplete paralysis, as well as a complete sensory loss in both lower extremities. Urinary incontinence developed, as did severe low-back pain. Physical examination revealed blood pressure of 185/110. The patient had a sensory level at C3–C4 with paraplegia and severe paresis of the upper extremities. Plain films of the cervical spine were not contributory. Myelography disclosed a complete transverse block at the C6–C7 level with separation of the column of contrast material from the left pedicle, findings consistent with an extradural lesion at that level (Fig. 1). A dorsolumbar laminectomy was performed July 19. A large epidural hematoma, which depressed the dura, was found at T9—L2 on the right and was evacuated. The patient has shown minimal improvement postoperatively and at the time of this report is still hospitalized.