Translate this page into:
Lumbar Extradural Spontaneous Hematoma with Acute Paraparesis
Address for correspondence: Deepak Hegde, Department of Orthopaedics, K. S. Hegde Medical Academy, Nitte University, Deralkatte, Mangalore - 575 018, India E-mail: deepakortho123@rediffmail.com
This article was originally published by Thieme Medical and Scientific Publishers Private Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Introduction
Primary epidural hematomas or “hematorrachis” are rare and less frequent in the lumbar region. It presents with acute onset of severe back pain and rapid development of signs of compression
Objective
To report a case of lumbar extradural spontaneous hematoma with acute paraparesis.
Case Report
A 65 year old male presented with acute back ache of 2weeks duration with Radicular pain and numbness of both feet. He had progressive asymmetrical weakness of the lower extremities without bowel/bladder involvement and inability to walk. Radiograph of spine shows Grade 1 listhesis of L4–L5. MRI of LS Spine s/o synovial cyst at L2–L3 level. Left Facet joint arthropathy L2–L3. Patient underwent L2 laminectomy with removal of synovial cyst and hematoma
Results
The patient had motor improvement of grade 3 power in hip and knee flexors and EHL AND EDL.3 months follow up showed grade 4 of all lower limb muscles with sensory numbness present on L3–L4 and L4–L5.
- SAGITAL IMAGES
- L2–L3 T2 TRUFI AXIAL IMAGES
- POST EVACUATION
Conclusion
Spontaneous spinal extradural hematoma should be suspected in any patient who complains of local or referred spinal pain associated with acute limb weakness, sensory deficits, with or without cauda equina symptoms.
Introduction
Primary epidural hematomas or “hematorrachis” are rare and less frequent in the lumbar region. It presents with acute onset of severe back pain and rapid development of signs of compression of cord.
Case report
A 65 year old male presented with acute back ache of 2weeks duration with Radicular pain and numbness of both feet. He had progressive asymmetrical weakness of the lower extremities without bowel/bladder involvement and inability to walk. No constitutional symptoms/trauma/systemic illness. He was a known alcoholic and smoker. On evaluation of the spine no deformity and paraspinal region normal.
Neurology
Upper limbs :normal, Straight leg raising test:bilateral free, Lower limbs :hip and knee -3/5, Ankle dorsiflexion-0/5, Plantar flexion-1/5, Toes-1/5. Sensations were reduced over L3–L4, L5–S1 dermatome bilaterally. Deep tendon reflexes were absent and Bilateral plantar reflexes were equivocal.
Investigations
Blood investigations: Bleeding profile is normal. Liver function tests are normal. Radiograph of spine shows Grade 1 listhesis of L4–L5. MRI of LS Spine s/o synovial cyst at L2–L3 level. Left Facet joint arthropathy L2–L3.
Treatment
Patient underwent L2 laminectomy with removal of synovial cyst and hematoma. The synovial cyst located on the left facet joint was removed. A large hematoma measuring about 3x4cm was present extradural compressing the spinal cord with adhesion over the dura was seen. A brownish red mass dorsally extending from L1 to L2 compressing the dura & cord was present. There was no active bleeding and no osseous involvement. The material was sent for biopsy. Histopathology shows hematoma, fibrous tissue and no evidence of tumour or synovial cells.
Postoperatively the patient had motor improvement of grade 3 power in hip and knee flexors and EHL AND EDL. 3 months follow up showed grade 4 of all lower limb muscles with sensory numbness present on L3–L4 and L4–L5.
Conclusion
Spontaneous spinal extradural hematoma should be suspected in any patient who complains of local or referred spinal pain associated with acute limb weakness, sensory deficits, with or without cauda equina symptoms.
Discussion
Spontaneous Spinal Extradural Hematoma
“Hematorrachis”.First case was seen in I897, William Bain. It is a rare entity. It has a frequency of <1 % of spinal space-occupying lesions. AETIOLOGY: Acute onset of severe back pain with rapidly develop signs of comrpression of cord or cauda equina. Predisposing factors include hemophilia, coagulopathy, anticoagulation (25 %–70 % of cases), vascular anamoly, Paget's disease. In many reports, spinal epidural hematomas develop in various traumatic conditions, including lumbar punctures, epidural anaesthesia, missile injury, fall down, being struck in the back by objects, spinal manipulation treatment and other blunt trauma of the back area. The pathogenesis of spinal epidural hematoma remains unknown. Some authours have suggested that spinal epidural hematoma may have developed due to bleeding from rupture of spinal epidural artery resulting from sudden stretching of these vessels. Others have advocated that spinal epidural hematoma might have originated from the epidural venous plexus. The veins in epidural venous plexus are composed of thin valve-less vessels. Therefore the veins may be vulnerable to rupture in conditions of sudden change in venous pressure. Diagnosis of spinal epidural hematoma is usually made using computed tomography scan or MRI. MRI in particular is critical for diagnosis of spinal epidural hematoma. MRI demonstrates location and extent of hematoma, degree of cord compression and provides the surgeon with the necessary information to plan appropriate management for this condition. MRI can also differentiate between various potential causes of neurologic deficits in patients with spinal injuries, such as traumatic disc rupture, spinal cord edema, spinal cord contusion, spinal canal encroachment by fractured bony fragment and spinal subdural or subarachnoid haemorrhage. Prompt surgical evacuation of hematoma with laminectomy has been regarded as standard treatment for symptomatic spinal epidural hematoma. Critical factors related to outcome are the preoperative neurological deficits, the time interval from the onset of symptoms to surgical decompression, the duration of complete neurologic symptoms and the intramedullary signal intensity on the MRI. In our case, we prepared for emergent evacuation of the spinal epidural hematoma by multilevel laminectomy after the MRI. However, the patients neurologic symptoms, especially paraplegia, improved rapidly about 24hours after the onset of initial symptoms with surgical interventions.
References
- Facet cyst haematoma in the lumbar spine: a report of four cases. Journal of Orthopaedic Surgery. 2009;17((1)):80-4.
- [Google Scholar]
- “Spontaneous Epidural Hematoma Presenting as Paraplegia”: A Case Report. Arch Phys Med Rehabil. 2005;Vol 86:2.
- [Google Scholar]
- “Acute Spontaneous Spinal Epidural Hematoma Causing Cauda Equina Syndrome”: A Case Report. Arch Phys Med Rehabil. ;Vol 76(2):1995.
- [Google Scholar]
- “Primary cavernous hemangioma of epidural space with compressive features”: A rare entity.
- [Google Scholar]
- J. Spinal Surg. 2010;Vol 2((1))
- Rapid spontaneous resolution of a traumatic cervical epidural hematoma. Br J NeuroSurg. 2005;19:451-2.
- [Google Scholar]