Complications of Spinal Cord Stimulators-A Comprehensive Review Article.

PURPOSE OF REVIEW: Spinal cord stimulation has been increasing in influence as an option to regulate pain, especially in the chronic pain patient population. However, even with the numerous changes made to this technology since its inception, it is still prone to various complications such as hardware issues, neurological injury/epidural hematoma, infections, and other biological concerns. The purpose of this article is to thoroughly review and evaluate literature pertaining to the complications associated with percutaneous spinal cord stimulation. RECENT FINDINGS: Lead migration is generally the most common complication of percutaneous spinal cord stimulation; however, recent utilization of various anchoring techniques has been discussed and experienced clinical success in decreasing the prevalence of lead migration and lead fractures. With newer high-frequency systems gaining traction to improve pain management and decrease complications as compared to traditional systems, rechargeable implantable pulse generators have been the preferred power source. However, recent findings may suggest that these rechargeable implantable pulse generators do not significantly increase battery life as much as was proposed. Intraoperative neuromonitoring has seen success in mitigating neurological injury postoperatively and may see more usage in the future through more testing. Though the occurrence of infection and biological complications, including dural puncture and skin erosion, has been less frequent over time, they should still be treated in accordance with established protocols. While many complications can arise following percutaneous spinal cord stimulator implantation, the procedure is less invasive than open implantation and has seen largely positive patient feedback. Hardware complications, the more common issues that can occur, rarely indicate a serious risk and can generally be remedied through reoperation. However, less common cases such as neurological injury, infections, and biological complications require prompt diagnosis to improve the condition of the patient and prevent significant damage.

Anterior spinal cord syndrome from a spinal epidural hematoma following removal of an epidural catheter.

PURPOSE: Spinal epidural hematoma (SEH) is a rare yet significant complication associated with neuraxial anesthesia. Here, we present the case of a 74-yr-old male who underwent open repair of an abdominal aortic aneurysm. Following the removal of an epidural catheter, the patient developed anterior spinal cord syndrome due to an SEH despite having a normal coagulation profile. CLINICAL FEATURES: This patient's neurologic presentation was marked by a loss of motor function while maintaining fine touch sensation distal to the spinal cord injury. Initial truncal computed tomography (CT) angiography failed to detect vascular compromise or diagnose the SEH. Subsequently, delayed magnetic resonance imaging (MRI) revealed a multilevel thoracic epidural hematoma, spinal cord infarction, and ischemia. Immediate surgical decompression was performed, but unfortunately, the patient had a poor outcome. CONCLUSION: Anterior spinal cord syndrome (ASCS) represents an uncommon neurologic manifestation of SEH, which is typically characterized by a triad of back pain and sensory and motor deficits. Although the initial CT scan was necessary to diagnose the postvascular surgery complication, it did not immediately detect the SEH. In cases of ASCS subsequent to thoracic epidural placement and removal, MRI is the preferred imaging modality for precise diagnosis and assessment of the need for surgical intervention. Despite adherence to anticoagulation guidelines, patients undergoing neuraxial anesthesia may face an elevated risk of developing SEH. Health care professionals should remain vigilant in monitoring for neurologic abnormalities following epidural catheter insertion or removal, particularly in the context of vascular surgery.

RéSUMé: OBJECTIF: L'hématome péridural rachidien est une complication rare mais importante associée à l'anesthésie neuraxiale. Nous présentons ici le cas d'un homme de 74 ans qui a bénéficié d'une réparation ouverte d'un anévrisme de l'aorte abdominale. Après le retrait d'un cathéter péridural, le patient a développé un syndrome médullaire antérieur dû à un hématome péridural rachidien malgré un profil de coagulation normal. CARACTéRISTIQUES CLINIQUES: La présentation neurologique de ce patient était marquée par une perte de la fonction motrice tout en conservant une sensation de toucher fine distale à la lésion médullaire. L'angiographie initiale par tomodensitométrie (TDM) n'a pas permis de détecter d'atteinte vasculaire ni de diagnostiquer un hématome péridural rachidien. Par la suite, une imagerie par résonance magnétique (IRM) retardée a révélé un hématome péridural thoracique à plusieurs niveaux, un infarctus médullaire et une ischémie. Une décompression chirurgicale immédiate a été réalisée, mais malheureusement, l'issue a été mauvaise pour le patient. CONCLUSION: Le syndrome médullaire antérieur représente une manifestation neurologique peu fréquente de l'hématome péridural rachidien, qui se caractérise généralement par une triade de maux de dos et de déficits sensoriels et moteurs. Bien que la tomodensitométrie initiale ait été nécessaire pour diagnostiquer la complication chirurgicale post-vasculaire, elle n'a pas immédiatement détecté l'hématome péridural rachidien. Dans les cas de syndromes médullaires antérieurs consécutifs à la pose et au retrait d'un cathéter péridural thoracique, l'IRM est la modalité d'imagerie privilégiée pour un diagnostic précis et une évaluation de la nécessité d'une intervention chirurgicale. Malgré le respect des directives d'anticoagulation, les patient·es bénéficiant d'une anesthésie neuraxiale peuvent faire face à un risque élevé de développer un hématome péridural rachidien. Les professionnel·les de la santé doivent demeurer vigilant·es dans le monitorage des anomalies neurologiques à la suite de l'insertion ou du retrait d'un cathéter péridural, en particulier dans le contexte d'une chirurgie vasculaire.

Good outcome with conservative treatment of delayed spinal epidural hematoma following combined spinal-epidural anesthesia: a rare case report.

BACKGROUND: Delayed spinal epidural hematoma (SEH) following central neuraxial block (CNB) is a rare but serious complication. The underlying causes of SEH associated with neuraxial anesthesia are still unclear. Furthermore, the decision between surgical intervention and conservative management for SEH remains a complex and unresolved issue. CASE PRESENTATION: We report a case of delayed SEH in a 73-year-old woman who underwent vaginal hysterectomy under combined spinal-epidural anesthesia, with the administration of postoperative anticoagulants to prevent deep vein thrombosis on the 1st postoperative day (POD). She experienced symptoms 56 h after CNB. Magnetic resonance imaging (MRI) revealed a dorsal SEH at the L1-L4 level with compression of the thecal sac. On conservative treatment, full recovery was achieved after six months. CONCLUSIONS: This case reminds anesthesiologists should be alert to the possible occurrence of a delayed SEH following CNB, particularly with the administration of anticoagulants. Immediate neurological evaluation of neurological deficit and MRI are advised. Conservative treatment combined with close and dynamic neurological function monitoring may be feasible for patients with mild or nonprogressive symptoms even spontaneous recovery.

Non-traumatic bilateral epidural hematoma in a child with sickle cell anemia: A case report and a review of the literature.

OBJECTIVE: To report a rare case of spontaneous bilateral epidural hematoma (EDH) in a 10-year-old Nigerian child with sickle cell disease (SCD) and review the literature regarding this unusual complication. METHODS: We present a case of a pediatric patient with SCD who developed a spontaneous bilateral EDH and discuss the potential underlying mechanisms, management approaches, and outcomes. We also conducted a literature review of existing cases of spontaneous EDH in patients with SCD. RESULTS: Our patient initially presented with a subgaleal hematoma and underlying bilateral EDH, but she was sent home without any neurosurgical consultation. Two years later, she returned with altered consciousness and left-sided weakness, revealing an increased size of the EDH with a noticeable mass effect. She underwent a successful emergency bilateral craniotomy, with noticeable improvement in her level of consciousness and left-sided weakness post-operatively. In our literature review, we found 40 reported cases of spontaneous EDH in SCD patients, with a male predominance (82.5%). The average age of patients was 15.282 years. The most common hematoma location was bifrontal (20%) and the most reported symptom was headache (47.5%). Most patients (97.5%) were already known cases of SCD. Among those treated, 77.5% survived. CONCLUSION: Spontaneous bilateral EDH in SCD patients is an uncommon complication, with a variety of proposed pathophysiological mechanisms. Prompt recognition and appropriate management, either conservative or surgical, are crucial to improve outcomes. Our case and literature review underscore the importance of considering spontaneous EDH in SCD patients presenting with neurological symptoms, even in the absence of trauma. Further research is needed to elucidate the precise etiology, identify risk factors, and optimize management approaches for this rare complication in SCD patients.

Comparison of burr hole drainage and craniotomy for acute liquid epidural hematoma in pediatric patients.

PURPOSE: To compare the impact of burr hole drainage and craniotomy for acute liquid epidural hematoma (LEDH) in pediatric patients. METHODS: This retrospective study enrolled pediatric patients with LEDH who underwent surgery in the Affiliated Hospital of Nanyang Medical College, China, between October 2011 and December 2019. According to the surgical procedure, patients were divided into the craniotomy group and the burr hole drainage group. RESULTS: A total of 21 pediatric patients were enrolled (14 males, aged 7.19 ± 2.77 years), including 13 cases in the burr hole drainage group and 8 patients in the craniotomy group. The operation time and hospitalization period in the burr hole drainage group were 33.38 ± 6.99 min and 9.85 ± 1.07 days, respectively, which were significantly shorter than that in the craniotomy group (74.25 ± 9.68 min and 13.38 ± 1.71 days, respectively; all p < 0.05). The Glasgow Coma Scale (GCS) score after burr hole drainage was significantly improved than before (median: 15 vs 13, p < 0.05). No serious complications were observed in either group; one patient in the craniotomy group developed an infection at the incision point. All patients were conscious (GCS score was 15) at discharge. CONCLUSION: Compared with craniotomy, burr hole drainage was associated with better clinical outcomes and early recovery in patients with LEDH.

Pediatric head injuries: particularities and neurosurgical experience in a lower-middle income country.

PURPOSE: To the best of our knowledge, this is the first study conducted in Tunisia on the neurosurgical management of child cranial trauma. The objectives of the present work were to identify the causes of pediatric head injuries, explore epidemiological and clinical specificities, and analyze the short- and long-term postoperative evolution. METHODS: A retrospective review was conducted on one hundred children with head injuries over a five-year period at one of the largest neurosurgery departments in Tunisia. The collected data encompassed demographic information, clinical presentation features, neuroimaging characteristics, surgical management, complications, and outcomes. RESULTS: Over a five-year period, we have found 118 children who have undergone surgery, representing an annual incidence of twenty-four children per year. The average age was 10 years. Falls emerged as the primary cause of childhood head injuries in our series, followed by road traffic accidents. The most frequently encountered initial sign was the loss of consciousness (52%), followed by headaches (28%), vomiting (25%), and seizures (8%). The average time between the accident and admission to the operating unit was 10 h. Various neurosurgeries were performed, with the evacuation of an epidural hematoma being the most common procedure. At a median follow-up of 24 months, the outcomes were favorable in 88% of cases. CONCLUSION: The main prognostic factors for head trauma in children included age, circumstances of the accident, association with polytrauma, the initial Glasgow Coma Scale, the nature of the initial cerebral lesions, and the timeliness and quality of initial management.

Practical pearls for management of cranial injury in the developing world.

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69 million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

A pig model of symptomatic spinal epidural hematoma.

PURPOSE: The purpose of this study was to establish an animal model capable of simulating the development and decompression process of symptomatic spinal epidural hematoma (SSEH). METHODS: A total of 16 male Bama miniature pigs were included in this study and randomly allocated into four groups: Group A (4 h 20 mmHg hematoma compression), Group B (4 h 24 mmHg hematoma compression), Group C (4 h 28 mmHg hematoma compression), and Group Sham (control). Real-time intra-wound hematoma compression values were obtained using the principle of connectors. Electrophysiological analyses, including the latency and amplitude of somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP), along with behavioral observations (Tarlov score), were performed to assess this model. RESULTS: ANOVA tests demonstrated significant differences in the latency and relative amplitude of SSEP and MEP between Groups C and Sham after 4 h of hematoma compression and one month after surgery (P < 0.01). Behavioral assessments 8 h after surgery indicated that animals subjected to 28 mmHg hematoma compression suffered the most severe spinal cord injury. Pearson correlation coefficient test suggested a negative correlation between the epidural pressure and Tarlov score (r = -0.700, p < 0.001). With the progression of compression and the escalation of epidural pressure, the latency of SSEP and MEP gradually increased, while the relative amplitude gradually decreased. CONCLUSIONS: When the epidural pressure reaches approximately 24 mmHg, the spinal cord function occurs progressive dysfunction. Monitoring epidural pressure would be an effective approach to assist to identify the occurrence of postoperative SSEH.

Clinical outcome after surgical management of spontaneous spinal epidural hematoma.

PURPOSE: Spontaneous spinal epidural hematoma (SSEH) is a rare pathology characterized by a hemorrhage in the spinal epidural space without prior surgical or interventional procedure. Recent literature reported contradictory findings regarding the clinical, radiological and surgical factors determining the outcome, hence the objective of this retrospective analysis was to re-assess these outcome-determining factors. METHODS: Patients surgically treated for SSEH at our institution from 2010 - 2022 were screened and retrospectively assessed regarding management including the time-to-treatment, the pre-and post-treatment clinical status, the radiological findings as well as other patient-specific parameters. The outcome was assessed using the modified McCormick Scale. Statistical analyses included binary logistic regression and Fisher's exact test. RESULTS: In total, 26 patients (17 men [65%], 9 women [35%], median age 70 years [interquartile range 26.5]) were included for analysis. The SSEHs were located cervically in 31%, cervicothoracically in 42% and thoracically in 27%. Twenty-four patients (92%) improved after surgery. Fifteen patients (58%) had a postoperative modified McCormick Scale grade of I (no residual symptoms) and 8 patients (31%) had a grade of II (mild symptoms). Only 3 (12%) patients remained with a modified McCormick Scale grade of IV or V (severe motor deficits / paraplegic). Neither time-to-treatment, craniocaudal hematoma expansion, axial hematoma occupation of the spinal canal, anticoagulation or antiplatelet drugs, nor the preoperative clinical status were significantly associated with the patients' outcomes. CONCLUSION: Early surgical evacuation of SSEH generally leads to favorable clinical outcomes. Surgical hematoma evacuation should be indicated in all patients with symptomatic SSEH.

Management of Pediatric Patient with Multiple Cranial, Intracranial, and Spinal Manifestations of Penttinen Syndrome: A Case Report.

INTRODUCTION: Penttinen premature aging syndrome is caused by mutations in the PDGFRB gene. We describe the case of a 10-year-old girl with a de novo c.1994T>C variant in PDGFRB who developed multiple cranial, intracranial, and spinal manifestations, including macrocephaly, enlarged convexity subarachnoid spaces crossed by numerous vascularized arachnoid trabecule, hydrocephalus, spinal epidural lipomatosis, a low conus medullaris, calvarial thinning with large anterior fontanelle, and a skull fracture with bilateral epidural hematomas. Vascularized arachnoid granulations, spinal epidural lipomatosis, and low conus medullaris have not been previously described in Penttinen syndrome. CASE PRESENTATION: A female with Penttinen syndrome diagnosed at 9 years of age initially presented as an infant with cutaneous hemangiomas and macrocephaly; imaging showed enlarged convexity subarachnoid spaces. Her convexity subarachnoid spaces continued to expand, leading to subdural shunt placement. At surgery, her enlarged subarachnoid spaces were found to contain numerous abnormally thick, vascularized arachnoid trabecule. Eventually, her subdural shunt failed and her ventricles enlarged, leading to ventricular shunt placement. A large, sunken anterior fontanelle which did not diminish in size led to cranioplasty with a custom implant. She later developed chronic back pain and imaging revealed spinal epidural lipomatosis, a low conus medullaris, and mild scoliosis. At 10 years of age, a fall from a chair resulted in a depressed skull fracture and bilateral parietal epidural hematomas. Emergency left parietal craniotomy was performed for evacuation of the left hematoma, and the patient recovered without complications. Intraoperatively, it was noted that her skull was extremely thin. CONCLUSION: This case report highlights the clinical presentation and multifaceted neurosurgical management of a patient with Penttinen syndrome. The patient exhibited characteristic features including hypertrophic skin lesions, macrocephaly, and skeletal abnormalities. Our patient's vascularized arachnoid trabecule, spinal epidural lipomatosis, and low conus medullaris have not previously been reported in Penttinen syndrome. Her thin skull potentially contributed to the extent of her depressed skull fracture after her backwards fall and predisposed her toward developing epidural hematomas. Patients with Penttinen syndrome can have multiple cranial, intracranial, and spinal manifestations which may need the attention of a neurosurgeon.

Anti-HMGB1 mAb Therapy Reduces Epidural Hematoma Injury.

Epidural and subdural hematomas are commonly associated with traumatic brain injury. While surgical removal is the primary intervention for these hematomas, it is also critical to prevent and reduce complications such as post-traumatic epilepsy, which may result from inflammatory responses in the injured brain areas. In the present study, we observed that high mobility group box-1 (HMGB1) decreased in the injured brain area beneath the epidural hematoma (EDH) in rats, concurrent with elevated plasma levels of HMGB1. Anti-HMGB1 monoclonal antibody therapy strongly inhibited both HMGB1 release and the subsequent increase in plasma levels. Moreover, this treatment suppressed the up-regulation of inflammatory cytokines and related molecules such as interleukin-1-beta (IL-1ß), tumor necrosis factor-alpha (TNF-α), and inducible nitric oxide synthase (iNOS) in the injured areas. Our in vitro experiments using SH-SY5Y demonstrated that hematoma components-thrombin, heme, and ferrous ion- prompted HMGB1 translocation from the nuclei to the cytoplasm, a process inhibited by the addition of the anti-HMGB1 mAb. These findings suggest that anti-HMGB1 mAb treatment not only inhibits HMGB1 translocation but also curtails inflammation in injured areas, thereby protecting the neural tissue. Thus, anti-HMGB1 mAb therapy could serve as a complementary therapy for an EDH before/after surgery.

Cervical epidural hematoma masquerading as thrombosis of intracranial flow diverter in situ: A diagnostic and therapeutic conundrum.

Cervical epidural hematoma (EDH) is a rare but very serious cause of acute neurologic compression that needs early diagnosis and rapid intervention. Acute hemiparesis is an infrequent presentation of cervical EDH and often mimics cerebrovascular accident. In this case, we describe the management of a case of cervical EDH presenting as acute hemiparesis in an elderly female patient which mimicked as thrombosis of intracranial flow diverter in situ. The report emphasizes that cervical EDH should be considered as differential diagnosis in patients who present with acute hemiparesis especially, who are on antiplatelets or anticoagulants. Also, in a patient considered high-risk for surgery, conservative management can be considered under close supervision and intensive monitoring, especially, in non-expanding hematoma and non-progressive neurological deterioration.

How to Avoid Misdiagnosing Spontaneous Cervical Spinal Epidural Hematoma as Ischemic Stroke: 3 Case Reports and Literature Review.

When spontaneous cervical spinal epidural hematoma (SCEH) presents with hemiparesis, it can be misdiagnosed with ischemic stroke (IS), and the treatment of IS such as thrombolysis may deteriorate the symptoms of patients with SCEH, leading to worse sequelae or even death. We reported 3 SCEH patients who were initially suspected as IS in our center between Jun 2020 and April 2022 and analyzed their clinical characteristics together with 48 patients reported in the literature from Jan 1995 to April 2022. Two of the 3 SCEH patients had neck symptoms, while none of them presented cranial nerve symptoms. Cranial computed tomography (CT) scans were negative; however, abnormal signals in the cervical spinal canal were observed during cranial computed tomography angiography (CTA) and subsequent cervical CT confirmed the diagnosis of SCEH. All of them avoid mistreatment with recombinant tissue plasminogen activator (rt-PA). Subsequently, we analyzed the clinical characteristics of a total of 51 patients. Thirteen of them developed symptoms during activity. Neck pain was an important sign of SCEH because 35 patients had neck pain or neck discomfort. Sensory impairment was reported in a small proportion of patients (11/51), which varied a lot in the patients. Some special manifestations highly suggested spinal cord lesions and provided evidence for the early differential diagnosis of SCEH and stroke, but the incidence of which was quite low: ipsilateral Horner syndrome in 2 patients, Brown-Séquard syndrome in 2 cases, and Lhermitte's sign in 1 case. Only a minority (8/51) of the patients were correctly diagnosed at the emergency unit using cervical CT. Six patients were correctly diagnosed when performing CTA. A large portion of the cases (21/51) were first misdiagnosed as IS, but no responsible lesions were found on cranial magnetic resonance imaging (MRI), and subsequent cervical MRI confirmed the diagnosis. Sixteen patients were diagnosed with SCEH after the deterioration of symptoms. A total of 13 patients received rt-PA, and 10 of them had symptoms aggravation after thrombolysis. For patients with acute onset of hemiparesis but without cranial nerve symptoms, especially those accompanied by clinical features such as neck pain, ipsilateral Horner syndrome, Brown-Séquard syndrome, and Lhermitte's sign, SCEH should be highly suspected rather than stroke. Careful differential diagnosis should be performed with a comprehensive medical history and thorough physical examination. Cervical CT scan is a reasonable choice for quick differential diagnosis prior to administering potentially harmful therapy, especially rt-PA.

Paradoxical contralateral hemiparesis in spontaneous spinal epidural hematoma: a case report.

BACKGROUND: Hemiparesis associated with spontaneous spinal epidural hematoma (SSEH) usually occurs ipsilateral to the hematoma. We here report the case of a patient with paradoxical hemiparesis contralateral to a spinal lesion due to SSEH. CASE PRESENTATION: A 70-year-old woman was identified in routine clinical practice; she presented with acute-onset neck pain and left hemiparesis. Neurological examination showed left-sided sensory-motor hemiparesis without facial involvement. Cervical MRI showed a dorsolateral epidural hematoma compressing the spinal cord at the C2 to C3 level. Axial imaging demonstrated a crescent hematoma on the right side, which is contralateral to the hemiparesis, and lateral displacement of the spinal cord. Spinal angiography revealed no abnormal vessels. Based on clinical presentation and MRI findings, a diagnosis of SSEH was made. The patient was managed conservatively. The symptoms completely resolved without any neurological deficits, and the hematoma disappeared on the follow-up MRI. CONCLUSIONS: Paradoxical contralateral hemiparesis is one of the possible presenting symptoms in patients with SSEH. This case demonstrates the existence of the paradoxical contralateral hemiparesis associated with spinal compressive lesions. A plausible mechanism of the phenomenon is discussed.

Isolated pediatric retroclival epidural hematoma following a minor blunt head trauma: a case report with review of the literature.

Post-traumatic clival hematomas are a rare entity and almost exclusive to the pediatric population. Those of retroclival location are exceptionally rare. This entity was first described in 1941 by Coleman and Thomson, and since then, less than 30 cases have been reported in the literature. Clinically, these hematomas are usually silent and slow, but clinical state worsening may be sudden and rapidly fatal by the onset of obstructive hydrocephalus in the absence of prompt treatment. Here, the authors report a new case of pediatric post traumatic retroclival epidural hematoma following a minor blunt head trauma in a 03-year-old male patient with good outcomes. The authors will proceed with a review of the literature regarding the pathophysiology and mechanisms of occurrence of such post-traumatic injury.

Insidious onset of spontaneous spinal epidural hematoma in immune thrombocytopenic purpura: a case-based review.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) can result from various etiologies with a variable degree of neurological deficits. Here, we describe a rare case of SEH secondary to immune thrombocytopenic purpura (ITP) in a child and review the literature of SSEH caused by ITP. CASE REPORT: A 9-year-old female who presented with rapid neurological decline, including bowel and bladder incontinence and paraparesis. A SSEH was observed extending from C2 to T6, causing a mass effect on the spinal cord. Her platelet count was only 7000/µL. Multidisciplinary care was established with neurosurgery, pediatric hematology, and pediatric surgery. The patient was managed emergently with splenectomy and surgical evacuation, with multilevel laminectomy and laminoplasty for evacuation of the hematoma. After a short course of rehabilitation, the patient regained all neurological function. CONCLUSION: We report the first case of cervicothoracic SSEH secondary to ITP in a child managed with emergent splenectomy and surgical evacuation with multilevel lamoplasty. We also described the methods of timely diagnosis, urgent management, and overall prognosis of patients with this condition.

Spontaneous spinal epidural hematoma in a toddler presenting with torticollis: case report and literature review.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is a rare entity, especially in toddlers and infants. The nonspecificity of its presenting symptoms in children may be a source of delayed diagnosis. CASE DESCRIPTION: We report the case of a 20-month-old young boy without medical history who presented with irreducible torticollis, worsened a few days later by severe tetraplegia and respiratory distress. Spinal magnetic resonance imaging (MRI) showed a posterior epidural hematoma, extending from C3 to T1 and compressing the spinal cord. An urgent decompressive surgery via an extensive laminectomy and evacuation of the clot was performed. The patient demonstrated a partial neurological recovery on follow-up. CONCLUSION: SSEH is a rare and serious condition that may compromise the functional and vital prognosis of the patient, hence the importance of prompt diagnosis and urgent treatment.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs.

OBJECTIVE: Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. DESIGN: A retrospective cohort study. SETTING: In the operating room. PARTICIPANTS: Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. CONCLUSIONS: In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Screw fixation without fusion for low lumbar chance fracture accompanied by spinal epidural hematoma in patient with ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory disease involving the sacroiliac joint and axial spine. AS may render the ankylosed spine prone to trauma and cause an increased frequency of associated epidural hematomas in spine fractures. Herein, we report a rare case of L5 chance fracture and epidural hematoma in a 27-year-old female patient with AS. She was treated surgically but without bone fusion or decompressive laminectomy due to the neurologically intact status despite significant neural compression by the spinal epidural hematoma (SEH). We believe that conservative treatment with close observation of neurological status may be effective in SEH presenting with mild neurological symptoms despite significant neural compression.

Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications.

PURPOSE: Spontaneous spinal epidural hematoma (SSEH) is a rare but disabling disease. Although several cases have been reported in the literature, their treatment remains unclear, especially in patients with advanced age. We, therefore, aimed to describe the clinical outcomes of cervical SSEH in octogenarians with an acute onset of neurological illness undergoing laminectomy. METHODS: Electronic medical records from a single institution between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, functional status, surgical characteristics, complications, hospital course, and 90-day mortality were also collected. RESULTS: Twenty-two patients aged ≥ 80 years with SSEH undergoing laminectomy were enrolled in this study. The mean Charlson comorbidity index was 9.1 ± 2.0, indicating a poor baseline reserve. Ten individuals (45.5%) were taking anticoagulant agents with a pathologic partial thromboplastin time (PTT) of 46.5 ± 3.4 s. Progressive neurological decline, as defined by the motor score (MS), was observed on admission (63.8 ± 14.0). The in-hospital and 90-day mortality were 4.5% and 9.1%, respectively. Notably, the MS (93.6 ± 8.3) improved significantly after surgery (p < 0.05). Revision surgery was necessary in 5 cases due to recurrent hematoma. Anticoagulant agents and pathological PTT are significant risk factors for its occurrence. Motor weakness and comorbidities were unique risk factors for loss of ambulation. CONCLUSIONS: Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits. Emergent surgery seems to be the "state of the art" treatment for SSEH. However, potential complications associated with adverse prognostic factors, such as the use of anticoagulants, should be considered.