A 33-year-old male patient experienced temporary sensory loss and weakness in the right lower extremity one month prior to admission. The patient was admitted to a private clinic with a three-day history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the Guillain-Barre syndrome (GBS). The patient was subsequently transferred to our clinic and the neurologic examination revealed paraplegia in both lower extremities, positive bilateral Babinski signs, and hypesthesia below the T10 dermatome with saddle anesthesia. The patient had urinary incontinence and thoracic magnetic resonance imaging (MRI) showed an image of a mass compressing the medulla.
Acute spontaneous spinal epidural hematoma (ASSEH) is a rare condition that requires emergency intervention in the presence of neurological deficit [
The ASSEH patients with progressive neurological deficit require urgent decompression of the spinal cord and the evacuation of the hematoma [
In this report, we present a case who was admitted with progressive paraplegia three days after the onset of the complaints and whose diagnosis was delayed during the investigation of the neurological signs.
A 33-year-old male patient presented to a private clinic with a three-day history of acute onset of sensory loss and weakness in both lower extremities. The patient presented to our emergency service when the neurological signs were being investigated by a neurologist in the previous clinic. On admission, the patient had no history of trauma, bleeding disorder, and hypertension. The neurological examination revealed paraplegia in both lower extremities, positive bilateral Babinski signs, and hypesthesia below the T10 dermatome with saddle anesthesia. The anal sphincter tone and bilateral tendon reflex were reduced. The blood levels were in normal range and the blood coagulation tests revealed normal international normalized ratio (INR) and activated partial thromboplastin time (APTT). Cervical, thoracic, and lumbar MRI scans revealed that a hyperintense signal change on T1-weighted and an isointense signal change on T2-weighted images were compressing the spinal cord (Figure
Preoperative thoracic sagittal T1, T2 MRI and axial T2 MRI.
Thoracic spinal epidural hematoma images during surgery.
Postoperative thoracic sagittal T1-T2 MRI.
Postoperative thoracic sagittal T1-axial T2 MRI fields marked hemilaminectomy.
Spontaneous epidural hematomas (SEHs) can be classified into two categories: traumatic and spontaneous. Traumatic SEHs are considered to occur secondary to spinal surgeries, lumbar puncture, vertebral fractures, and any spinal intervention [
ASSEH can be seen in all age groups, with the highest incidence in males and patients aged over 40–50 years. However, ASSEH is very rarely seen in children [
Ventral SSEH is highly rare since the dural sac is firmly attached to the posterior longitudinal ligament. Anterior SSEH has also been reported, though very rare [
SSEH mostly occurs in the lumbar region in patients aged over 40 years and in the cervical and thoracic segments in patients aged below 40 years and children [
The source of bleeding in SSEH remains unknown [
SSEH is mostly presented by a sudden onset of pain in the neck and back and weakness. This pain is of a radicular character and may radiate to the extremities. Within hours or days, due to the compression of the spinal cord, these symptoms may lead to varying degrees of motor and sensory loss. Diagnosis of SSEH is difficult to establish prior to the onset of neurological deficit. Therefore, the differential diagnosis of SSEH should include pulmonary emboli, spontaneous pneumothorax, and acute myocardial infarction in the absence of neurological deficit and should include transverse myelitis, GBS, epidural subarachnoid bleeding, and acute spinal cord ischemia in the presence of neurological deficit [
MRI remains the method of choice in the diagnosis of SSEH. MRI provides useful outcomes in the visualization of the location and the size of the hematoma as well as the presence of the spinal cord compression and edema. SSEH yields an isointense signal change on T1-weighted images within the first 24 h after bleeding and a hyperintense signal change on T2-weighted images after 24 h [
Urgent decompression of the spinal cord, regardless of the cause of bleeding, in the SSEH patients with neurological deficit is the initial step to be performed for the recovery from neurological deficit and for the classification of the hematoma [
The preoperative neurological status and the interval between the onset of symptoms and operation are key factors for the prognosis [
Conventional SSEH treatment includes total laminectomy and the evacuation of the hematoma. However, we performed hemilaminectomy, which is a minimally invasive method, for the evacuation of the hematoma and we believe that this method can be preferred in order to prevent the risk of postoperative complications such as kyphotic deformities and instability.
ASSEH should be kept in mind in the patients presenting with neurological deficit and a sudden onset of pain in the back. Urgent decompression surgery is the mainstay treatment in the patients with ASSEH and should be performed in order to avoid the risk of adverse outcomes. Neurogenic claudication may occur secondary to the compression of the spinal cord with no invasion into the neural tissue; therefore, surgical intervention is the ideal method for achieving complete recovery. In the cases where radiological differential diagnosis is difficult to perform, the surgery should be initiated by a minimally invasive approach and the surgeons should be prepared for the surgeries that may be needed for other diagnoses. MRI is the golden standard for the differential diagnosis of the patients suspected with SSEH.
In the cases with normal neurological findings, the surgeons may prefer to wait for the resorption to occur by performing repeated examinations and radiological follow-ups. Moreover, the absence of underlying diseases is also a possible condition, though rare.
The authors declare that they have no competing interests.