Spontaneous spinal hematomas: A case series.

PURPOSE: Spontaneous spinal hematoma (SSH), a rare neurological disorder, demands immediate diagnostic evaluation and intervention to prevent lasting deficits. This case series analyzes instances, particularly highlighting cases where vascular causes were identified despite inconclusive initial imaging. METHODS: In a retrospective study of 20 patients treated for SSH at a Level I spine center from 01/01/2017 to 11/15/2023, we examined demographics, clinical presentation, imaging, and treatment details. Excluding traumatic cases, we present 4 instances of SSH associated with diverse vascular pathologies. RESULTS: Patient ages ranged from 39 to 85 years, with a median age of 66 years. 45% were male, and 55% were female. Among 20 cases, 14 were epidural hematomas, 4 subdural, 1 combined epidural and subdural, and 1 subarachnoid hemorrhage. 85% presented with neurological deficits, while 3 solely had pain-related symptoms. 55% were under anticoagulant medication, and vascular anomalies were found in 25% of cases. The cause of SSH remained unclear in 20% of cases. MRI was performed for all patients, and DSA was conducted in 25% of cases. The 4 highlighted cases involved individuals with distinct vascular pathologies managed surgically. CONCLUSION: Urgent attention is crucial for SSH due to possible lasting neurological consequences. The study emphasizes comprehensive diagnostics and surgical exploration, especially in cases with unclear etiology, to identify and address vascular causes, preventing hematoma progression or recurrence. Despite their rarity, vascular malformations contributing to spinal hematomas warrant particular attention.

Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis.

BACKGROUND: Spinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery. METHODS: We retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively. RESULTS: None of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808). CONCLUSIONS: SSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.

Non-iatrogenic spontaneous acute spinal subdural haematoma after transforaminal lumbar interbody fusion.

PURPOSE: Reporting a rare case of a non-iatrogenic spontaneously resolved spinal subdural haematoma (SSDH) following revision of transforaminal lumbar interbody fusion (TLIF) and its possible explanation. METHODS: Case report of a 40-year-old man with a history of persistent lower back and left lower extremity radicular pain, secondary to recurrent disc prolapse, lumbar spondylosis with foraminal stenosis. He underwent an L5/S1 transforaminal interbody fusion via a right sided approach (through previous lumbar microdiscectomy incision). On post-operative day two, the patient developed headache and photophobia that were discovered to be secondary to an acute thoracolumbar subdural haematoma with no objective neurological deficit. RESULTS: After close observation of his neurological status and conservative management of the subdural haematoma, the patient fully recovered from his symptoms and remained problem-free at 2-year follow-up. CONCLUSIONS: Although the occurrence of acute spinal subdural haematoma after spinal surgery is a rare complication following spinal surgery, its appropriate management relies on early recognition if significant morbidity is to be avoided.

Cranial subdural migrating to lumbar subdural space in a toddler.

Migrated spinal subdural haematoma (sSDH) is a significantly uncommon finding. This case involves a paediatric patient representing after cranial trauma with new abnormal gait and leg pain who was found to have a migrated sSDH. Literature review for reported cases of pathogenesis theories, causes and management was performed and summarised in this report. The authors concluded that new abnormal gait and leg pain in a paediatric patient with previous cranial trauma is an indication for spinal MRI if migrated subdural haematoma is suspected. Non-surgical management is generally tolerated, and steroids can be trialled for radiculopathy if clinically indicated.

Holocordic Spinal Sbdural Hematoma: A Challenging Management In Emergency: Literature Review.

OBJECTIVE: Spinal subdural hematoma (SSH) is a rare entity and the etiology has yet to be elucidated. Holocordic spinal hematomas represent an exception. The management of these patients remains controversial, due to their rarity and their extremely poor prognosis. METHODS: Electronic databases (MEDLINE, Scopus, and PubMed) were analyzed for studies published through April 2021, searching holocordic spinal subdural hematoma. Case reports, case series, and literature reviews were included. RESULTS: We found only 7 cases describing holocordic SSH reported in the literature, and we added the description of 1 case we managed at our institution, reaching a total of 8 cases. We discuss clinical and radiologic features, etiologic hypothesis, treatment strategies, and prognostic factors. CONCLUSIONS: The correct treatment of holocordic hematomas is not yet well standardized. Complete evacuation is not amenable, but surgical evacuation based on magnetic resonance imaging has shown to be the most effective therapeutic option, crucial in terms of prognosis, even if performed with some delay.

Spinal Subdural Hematoma: Rare Complication of Spinal Decompression Surgery.

OBJECTIVE: Spinal subdural hematoma (SSH) is a rare and infrequently reported complication of hemilaminectomy, laminectomy, and other spinal decompression surgeries. In this review, we aim to analyze the available literature for reported cases of SSH to better identify risk factors and presenting symptoms, as well as highlight the importance in prompt investigation and management of SSH to prevent long-term morbidity and chronic neurologic deficit. METHODS: A review of the medical literature was undertaken using search terms hemilaminectomy OR laminectomy AND spinal subdural haematoma. All identified reports were screened for language, adult population, and human studies. Report abstracts were screened for relevance to question, with SSH occurring postoperatively following hemilaminectomy or laminectomy included. Four reports were included in the review. CONCLUSIONS: SSH is a rare, emergency condition with neurologic deficit that can present as recurrent back pain and acute cauda equina postoperatively following hemilaminectomy and laminectomy procedures. Vigilance, early investigation, and surgical evacuation is important in preventing short- and long-term morbidity. Further collation of data and analysis is required to better identify patients at high risk for developing SSH postoperatively.

Iatrogenic intra-spinal subdural haematoma: An exceptionally rare phenomenon.

Spinal subdural haematoma (SSDH) is very rare but potentially life debilitating spinal vascular condition, often developing acutely. Usually managed conservatively but may require immediate evacuation to prevent potential harm to the spinal cord. Predisposing factors can be spontaneous or iatrogenic. MRI remains the modality of choice to diagnose and see the age and extent of haemorrhage. We hereby present the case of a young child who developed iatrogenic spinal subdural haematoma.

Spinal subdural hematoma and subdural anesthesia following combined spinal-epidural anesthesia: a case report.

BACKGROUND: Subdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal-epidural anesthesia. CASE PRESENTATION: A 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34+ 5 weeks underwent cesarean delivery. Routine combined spinal-epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal. CONCLUSIONS: All anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.

Dorsal subdural hemorrhage from ruptured thoracic radicular artery pseudoaneurysm. case report and surgical video.

Radiculomedullary artery malformations are rare conditions: their rupture usually manifests with subarachnoid hemorrhage. To the best of our knowledge no cases of subdural bleeding have been described in the literature. We present the rare case of a 74 year old woman admitted to our Institute with sudden onset of right lower limb motor deficit and hypoesthesia, with no history of trauma: Magnetic Resonance Imaging of the dorsal spine was performed and a subdural hematoma was detected; subsequent dorsal laminectomy for hematoma evacuation was carried out. As the source of bleeding was not recognized, Digital Subtraction Angiography (DSA) was performed: a new leak of contrast agent from a dilation of a spinal radicular artery at the level of T5 was detected; XperCT imaging (an angiographic acquisition of Computed Tomography-like images) confirmed a new acute subdural bleeding. Urgent repeat surgery was considered the best option to identify and close the malformation. Postoperative DSA confirmed complete exclusion of the radicular artery malformation. This is the first report that describes, with an intraoperative video, a case of radiculomedullary artery pseudoaneurysm, responsible of an acute subdural bleeding and associated neurological deficit.

Risk Factor Analysis and Surgical Outcomes of Acute Spontaneous Spinal Subdural Hematoma. An Institutional Experience of Four Cases and Literature Review.

OBJECTIVE: Spontaneous spinal subdural hematoma (SSSDH) is exceedingly rare, with significant morbidity in most patients. Acute neurologic deficit in the context of a SSSDH is considered a neurosurgical emergency. We performed a literature review and compared the results with our institutional experience to evaluate the risk factors and neurologic outcomes of SSSDH. METHODS: We retrospectively collected the medical, radiologic, and surgical information of 4 patients with SSSDH who were operated on in our neurosurgical unit. A literature review of surgically managed patients with SSSDH and their neurologic outcomes was performed. Ordered logistic regression statistics were used to study the risk factors influencing the postoperative Domenicucci grade. RESULTS: A total of 112 patients were evaluated, with a female/male ratio of 1.3:1. Mean patient age was 60.25 years. Our analysis of the data showed that the cohort of patients presenting with bladder dysfunction in addition to paraparesis were found to have worse neurologic outcomes postoperatively. Adjusted analysis identified 3 clinical characteristics that influenced surgical outcome: cervical SSSDH (P = 0.029), neurologic deficit (P < 0.001), and anticoagulation medication (P < 0.001). CONCLUSIONS: This review shows that patients aged ≥60 years and on anticoagulation are at an increased risk of sustaining a spontaneous subdural spinal hematoma without history of trauma. To our knowledge, this is also the first study to show a presenting symptom of bladder dysfunction as a significant risk factor for poor surgical outcome in SSSDH. Our study supports surgical evacuation of acute SSSDH in the presence of these risk factors.

An Acute Spinal Intradural Hematoma after an Extraforaminal Wiltse Approach: A Case Report and Review of the Literature.

A nontraumatic spontaneous spinal acute subdural hematoma (sSDH) is a rare complication after spinal surgery. Although an sSDH is often associated with anticoagulation therapy, vascular malformations, or lumbar puncture, the pathogenesis of nontraumatic spontaneous sSDH remains unclear. We present the case of an intradural hematoma after an extraforaminal surgery through the Wiltse approach for an extraforaminal disk herniation at L5/S1. This 58-year-old woman experienced hypoesthesia and progressive motor dysfunction in the left leg several hours postoperation. Urgent magnetic resonance imaging revealed an intradural hematoma at the L1/L2 to L2/L3 level in the ventral dural sac proximal to the surgical level. Surgical decompression was performed. There was no evidence of trauma, coagulopathy, or anticoagulation therapy. To our knowledge, this case is the first to report an acute sSDH proximal to the surgery level after an extraforaminal spinal surgery through the Wiltse approach for an extraforaminal disk herniation. It illustrates that attentive postoperative neurologic monitoring, even in the absence of intraoperative irregularities, remains important to diagnose and treat this complication at the early stage.

Delayed Development of Spinal Subdural Hematoma Following Cranial Trauma: A Case Report and Review of the Literature.

BACKGROUND: Spinal subdural hematomas (SDHs) have been reported secondary to direct trauma or iatrogenic causes associated with coagulopathies. Spinal SDHs found after the development of acute intracranial SDHs, without any evidence of trauma to the spine, are extremely rare. In addition to this rare presentation, there is a lack of consensus regarding whether surgical decompression is the ideal treatment strategy. Depending on the extent of SDH within the spinal canal, surgical decompression may be difficult where diffuse hematoma within the intradural space requires multilevel decompression for treatment. CASE DESCRIPTION: A 46-year-old man initially presented with an acute cranial SDH following isolated head trauma. After a period of full recovery, he developed delayed lower extremity paraparesis secondary to the formation of a thoracolumbar SDH. This hematoma coincided with resolution of the cranial SDH and likely was due to redistribution of blood from the cranial subdural space into the spinal canal. Given the diffuse multilevel nature of the spread of hematoma and lack of a focal area of compression, he was managed conservatively. He demonstrated small signs of neurologic improvement over several days and regained considerable strength over the following several weeks. CONCLUSIONS: This report demonstrates a very rare occurrence of a traumatic intracranial SDH migrating into the thoracic and lumbar spine. This case also highlights that despite acute neurologic deficits, conservative management may be a feasible strategy that can result in recovery of neurologic function.

Spontaneous Spinal Subdural Hematoma after Percutaneous Mechanical Thrombectomy Combined with Catheter-Directed Thrombolysis for Deep Venous Thrombosis: A Case Report.

BACKGROUND: Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is one of the most important methods for deep venous thrombosis treatment. Spontaneous spinal subdural hematoma is a remarkably rare complication in the thrombolysis process with catastrophic consequences, as shown in this case report. METHODS: Percutaneous mechanical thrombectomy, percutaneous angioplasty, and catheter-directed thrombolysis were performed for the patient. Postoperatively, the patient was diagnosed with spontaneous spinal subdural hematoma and received a series of medical treatments and surgical interventions. RESULTS: The patient was still paraplegic and incontinent at the postoperative 7-month follow-up. CONCLUSIONS: Neurologic symptoms must be monitored carefully both during and after the thrombolysis procedure. The onset of spinal neurologic deficits in any patient must raise the suspicion that a spinal subdural hematoma has occurred. Surgical decompression beyond 24 hr may cause permanent neurological damage.

Spinal Epidural Hematoma Post Evacuation of Spontaneous Spinal Intradural Hematoma.

BACKGROUND: Spinal hematomas are rarely associated with dengue syndrome and usually occur at the time of active dengue fever. Late presentation after recovery from dengue fever, intradural hematoma, presentation as a multiloculated cystic lesion with longitudinal extensive myelitis, and recurrence after surgery are rarely or not described. Due to the peculiar association of all these findings, we report this case to provide insight into the existence of such a rare presentation. CASE DESCRIPTION: A 79-year-old-male developed sudden-onset paraparesis after 1 week of recovery from dengue fever. The blood counts were normal. Magnetic resonance imaging of the thoracic spine was suggestive of intradural hematoma. The patient underwent emergency decompression and drainage of hematoma with recovery in the neurologic status over the next few weeks. He presented to our emergency department after 5 weeks of the first surgery with deterioration in the neurologic status to complete paraplegia. Repeat magnetic resonance imaging showed a posterior epidural collection bulging anteriorly, causing cord compression. The patient was reoperated on by decompression. There was no neurologic recovery. The patient was managed with multidisciplinary rehabilitation, and he was independent in most of the activities at the time of discharge. CONCLUSIONS: Spinal hematoma should be kept in mind in patients who present with neurologic complications after dengue fever. It can have an atypical radiologic presentation and may present with recurrent hemorrhage after surgery. Attention should also be given to delayed presentation of neurologic complications, which may develop even after weeks of recovery from dengue fever.

Multiple Spinal Chronic Subdural Hematomas Associated with Thoracic Hematomyelia: A Case Report and Literature Review.

BACKGROUND: Chronic subdural hematoma (CSDH) is uncommon in the spine. Most spinal CSDHs occur as solitary lesions in the lumbosacral region. We report a rare case of multiple spinal CSDHs associated with hematomyelia. The diagnostic and therapeutic management of these complex spinal CSDHs is reviewed as well as the pertinent literature. CASE DESCRIPTION: A 79-year-old woman on warfarin therapy presented with lower back pain and progressive lower extremity weakness that had developed in the previous 2 weeks. She subsequently developed paraplegia and urinary incontinence. Thoracolumbar magnetic resonance imaging showed a CSDH from T12-L3 compressing the cauda equina. Single-shot whole-spine magnetic resonance imaging showed another CSDH and hematomyelia at T2-3. She underwent L2-3 hemilaminectomy, which revealed a liquefied subdural hematoma. Delayed T2 laminectomy exposed an organized subdural hematoma and xanthochromic hematomyelia. After each surgery, the patient showed significant motor recovery. Finally, the patient could walk, and the urinary catheter was removed. CONCLUSIONS: Spinal CSDH may occur in multiple regions and may be associated with hematomyelia. Whole-spine magnetic resonance imaging is useful to examine the entire spine for CSDH accurately and thoroughly. Comprehensive surgical exploration of all symptomatic hematomas may restore neurologic functions even with delayed surgery.