We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.
Spontaneous spinal epidural hematoma (SSEH) is uncommon, but the number of cases has increased with clarification of the clinical presentation of the condition using radiographic imaging. Here, we report three cases of SSEH with hemiparesis, which is uncommon compared to the classical presentation of SSEH as acute onset of severe irradiating back pain followed by paralysis.
The patient was a 73-year-old woman who experienced acute onset of severe pain in the back of her neck with radiation into her left shoulder. Over the next day, she developed left hemiparesis and was admitted to our hospital. An examination showed left hemiparesis (left upper and lower extremities; manual muscle testing (MMT) 1/5) with numbness in the left upper and lower extremities, without facial palsy, dysarthria, and aphasia. Deep-tendon reflexes were hypoactive on the left side with a left Babinski reflex. A head CT scan was normal, but a cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level (Figure
Preoperative sagittal (a) and axial (b) MR images showing a left posterolateral epidural hematoma at the C3-C6 level with spinal cord compression.
The patient was a 62-year-old man who experienced sudden pain of the posterior cervical region and numbness of the right lower extremity when he bent backward to administer eye drops. Subsequently, paralysis developed in the right upper and lower extremities, and he visited the emergency room of our hospital with suspicion of a cerebral stroke. An examination showed right hemiparesis (right upper and lower extremities; MMT 2/5) with numbness in the right upper and lower extremities and bladder and rectal disturbance, without facial palsy, dysarthria, and aphasia. Deep-tendon reflexes were hyperactive in the lower extremities with a right Babinski reflex. Head CT and MRI were normal, but cervical MRI showed a right dominant posterolateral spinal epidural hematoma at the C6-T1 level (Figure
Preoperative sagittal (a) and axial (b) MR images showing a right posterolateral dominant epidural hematoma at the C6-T1 level with spinal cord compression arrow.
A 60-year-old woman developed sudden pain of the posterior cervical region during a conversation. The pain aggravated gradually, and she developed left hemiparesis approximately 20 minutes after the onset of pain. Head CT and MRI were normal, but cervical MRI showed a spinal epidural hematoma limited to the left spinal dorsal region at the C2–C4 level (Figure
Initial sagittal (a) and axial (b) MR images showing a left posterolateral epidural hematoma at the C2-C4 level with spinal cord compression.
Spinal epidural hematoma was first described by Jackson [
The mechanism of development of SSEH is unclear. It has been suggested that venous pressure may increase in line with an increase in abdominal and intrathoracic pressure, since the spinal vein is of the primitive type with no venous valve, and that this may easily cause hemorrhage [
Development of SSEH is characterized by symptoms of sudden cervical or back pain followed rapidly by motor paralysis or anesthesia [