65-year-old man with atraumatic cervicothoracic spontaneous epidural hematoma
A 65-year-old man presented to the ED with 1 day of acute onset mid-thoracic and low back pain, difficulty ambulating and paresthesias in bilateral upper and lower extremities.
He denied any traumatic events or injuries prior to presentation. His pain localized to the midline thoracic region, radiating to the low lumbar spine. His past medical history included stage 4 chronic kidney disease (CKD) on hemodialysis, diabetes mellitus type 2 and congestive heart failure. He does not smoke. On physical examination, he had tenderness to the midline cervical spine and pain with cervical range of motion. His upper extremity physical examination demonstrated full strength throughout with diminished sensation bilaterally in the C6-T1 distributions. On motor examination of his lower extremities, he had 3 of 5 motor strength of the iliopsoas and quadriceps, and 2 of 5 motor strength of the tibialis anterior, extensor hallucis longus, gastrocnemius and flexor hallucis longus, bilaterally. Sensory examination was significant for decreased sensation in the L4-S1 distributions. Hoffman sign was negative. He did not demonstrate clonus. The rectal tone was diminished.
Post-void residual volume obtained in the ED was within normal limits. A MRI of the total spine was obtained in the setting of diminished rectal tone, which demonstrated an extensive ventral epidural collection that extended from C5-T3 with evidence of significant mass effect and cord compression at the cervicothoracic junction (Figures 1 and 2). The remainder of the thoracic and lumbar spine MRI did not demonstrate any further abnormalities. Serial neurologic exams over the course of 8 hours revealed new weakness in the intrinsic muscles of bilateral upper extremities and worsening back pain.
Source: Jared Tishelman, MD; Matthew S. Galetta, MD; and Kolawole Jegede, MD
What is the best course of treatment for this patient?
See answer below.
Decompressive laminectomy and hematoma evacuation
Given the patient’s acutely worsening neurologic deficits with imaging demonstrating a ventral epidural fluid collection that extended from C5-T3 with cord compression, the decision was made to proceed with surgical intervention. Surgical options included anterior decompression and fusion, posterior decompression and fusion or posterior-based decompressive surgery without instrumentation.
Due to his multiple medical comorbidities and high risk for nonunion, decompressive surgery with close follow-up to monitor postoperative global and local sagittal parameters were chosen. An urgent decompressive laminectomy and hematoma evacuation from C6-T2 was performed.
Operative procedure
After induction of general anesthesia and preposition neuromonitoring baselines were performed, the patient was positioned prone on a radiolucent cradle table, and a three-point head fixation frame was applied. An incision was made from the spinous process of C6-T2 in the midline and soft tissue dissection was carried down through the avascular plane to the spinous processes. Subperiosteal dissection was taken laterally to the lateral border of the lateral masses with care to preserve the capsules at all levels.
At this point, the hematoma began to extravasate from the interlaminar spaces. A partial dome laminectomy was performed at the caudal aspect of the C6 lamina and the cranial half of T2 lamina. The ligamentum flavum was released at the cranial and caudal aspects, and an en-bloc laminectomy was performed (Figure 3). This resulted in excellent visualization of the dura and the hematoma was irrigated from the spinal canal with copious saline irrigation.
Following extubation and transfer to the recovery room, the patient noted improved sensation to light touch in the C6-C8 and L4-S1 distributions in his bilateral upper and lower extremities, respectively. On postoperative day 1, the patient’s lower extremity strength had significantly improved to 4 of 5 strength in bilateral L4-S1 distributions. This continued to improve and by postoperative day 2, he had regained 5 of 5 motor strength in the bilateral lower extremities. His upper and lower extremity sensory examination also returned to baseline. He was discharged from the hospital on postoperative day 6 and kept in a rigid collar for 2 weeks.
Discussion
Spontaneous epidural hematoma (SEH) is a rare but serious condition that requires prompt recognition and intervention. SEH typically presents with acute onset of neck pain, which may radiate to the shoulders or arms. Neurologic symptoms, including weakness, paresthesia or paralysis, often follow rapidly. Some patients experience Brown-Séquard syndrome, characterized by ipsilateral motor weakness and contralateral sensory deficits. SEH should be considered, particularly in patients with end-stage renal disease (ESRD) on hemodialysis. These patients are at increased risk due to several pathophysiological mechanisms, primarily related to their altered coagulation status and vascular health.
The pathogenesis of SEH in patients with ESRD is multifactorial. Uremia-induced platelet dysfunction serves as a primary contributor, compromising normal hemostatic mechanisms. This is often compounded by the necessary use of anticoagulation during hemodialysis sessions. Hypertension, a common comorbidity in patients with ESRD, can further increase the risk of spontaneous bleeding through its negative effects on vascular integrity. Long-term hemodialysis patients may develop additional risk factors, including beta-2 microglobulin amyloidosis, which can cause structural weakness in the spine. Vascular malformations, more prevalent in patients with CKD, may also predispose to spontaneous hemorrhage. Furthermore, the hemodialysis process itself can induce fluctuations in intracranial pressure, potentially contributing to hematoma formation.
The decision-making process in this case involved assessing the risks and balancing the potential postoperative complications associated with post-laminectomy kyphosis vs. nonunion and pseudoarthrosis. Intraoperatively, there was an increased awareness of his coagulopathy related to ESRD. A posterior approach was utilized to access the epidural space and evacuate the hematoma. To minimize blood loss, intraoperative blood salvage was utilized and care was taken throughout the procedure to maintain meticulous hemostasis. En-bloc laminectomy allowed for complete decompression of the neural elements while minimizing both the morbidity of the procedure and postoperative complications.
The management of these patients requires careful consideration of their comorbidities and medical complexity. Early recognition of symptoms and prompt imaging studies are crucial for timely diagnosis and intervention. The presence of progressive neurologic deficits in a patient with ESRD, particularly when accompanied by back pain, should raise immediate suspicion for SEH. Postoperatively, the patient should be followed periodically for interval changes in their cervical spine sagittal alignment, specifically kyphosis at the cervicothoracic junction. Preoperative loss of cervical lordosis, intraoperative facet capsule destruction and posterior ligamentous disruption have all been implicated in increasing the risk of post-laminectomy kyphosis of the cervical spine after multilevel laminectomy, which may be as high as 21%. Therefore, patients should return every 6 months to 1 year with serial radiographs for cervical sagittal balance monitoring.
Key points
- Although rare, spontaneous epidural hematomas can be devastating and should be considered in patients suspectable to coagulopathy presenting with acute, atraumatic neurologic deficits.
- Prompt recognition and timely surgical decompression are critical to avoiding long-term neurologic consequences.
- References:
- An JX, et al. Chin Med J (Engl). 2013;126:286-289.
- Deger SM, et al. Intern Med. 2009;doi:10.2169/internalmedicine.48.2335.
- Goldstein CL, et al. Spine J. 2015;doi:10.1016/j.spinee.2013.11.043.
- Han IH, et al. Spine (Phila Pa 1976). 2009;doi:10.1097/BRS.0b013e3181abbdff.
- Ito M, et al. Spine (Phila Pa 1976). 1998;doi:10.1097/00007632-199810010-00018.
- Luo M, et al. Int J Surg. 2023;doi:10.1097/JS9.0000000000000538.
- Ng WH, et al. J Clin Neurosci. 2004;doi:10.1016/j.jocn.2003.12.002.
- Roy SP, et al. J Orthop Case Rep. 2012;2:23-25.
- Shahlaie K, et al. Pediatr Nephrol. 2004;doi:10.1007/s00467-004-1551-8.
- Takeshima Y, et al. Eur Spine J. 2012;doi:10.1007/s00586-011-2084-z.
- Vignes JR, et al. Spinal Cord. 2007;doi:10.1038/sj.sc.3101969.
- Yadav P, et al. World Neurosurg. 2016;doi:10.1016/j.wneu.2016.03.036.
- For more information:
- Matthew S. Galetta, MD; Kolawole Jegede, MD; and Jared Tishelman, MD, can be reached at NYU Langone Orthopedic Hospital in New York.
- Edited by Nicole Rynecki, MD, and Harold I. Salmons, MD. Rynecki is a chief resident in orthopedic surgery at NYU Langone. She will be pursuing a sports medicine fellowship at Hospital for Special Surgery following residency completion. Salmons is a chief orthopedic surgery resident at the Mayo Clinic. He will be pursuing an adult reconstruction fellowship at Hospital for Special Surgery following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
Collapse
Read more about