American Journal of Emergency Medicine 32 (2014) 291.e1–291.e3

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American Journal of Emergency Medicine

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Case Report

Rapid spontaneous recovery after development of a spinal epidural hematoma:a case report

Abstract

Spontaneous spinal epidural hematoma is a very rare clinicalemergency. A permanent neurological deficit or even death mayresult if diagnosis and treatment are delayed. Many cases can bediagnosed upon detailed neurological examination and magneticresonance (MR) imaging. Usually, surgery is required, but rarely, thecondition may improve spontaneously. A 46-year-old male patientwas admitted to our emergency department because of rapidlyevolving severe paraplegia following development of sudden-onsetneck pain. Spinal MR imaging detected an epidural hematomacompressing the spinal cord at the C5–T1 level. Clinical andradiological follow-up showed that the patient recovered spontane-ously in 48 hours without any need for surgical treatment.

Spinal epidural hematomas, which usually occur in the cervicaland thoracic regions, are very rare pathologies causing compression ofthe spinal cord. However, patients with this condition often requireemergency attention because the hematomas can trigger acuteneurological deficits [1,2]. We present a case of spontaneous spinalepidural hematoma (SSEH). Clinical and radiological data showed thatour patient improved rapidly, and spontaneously, over 48 hours offollow-up. We also review the relevant literature.

A 46-year-old male patient was admitted to our emergency roomcomplaining of sudden-onset back pain spreading to the neck, andthereafter, weakness in the arms and legs. The condition progressedrapidly, and the lower extremities were completely paralyzed within45 min. Upon neurological examination, weakness of grades 2/5 and3/5 was noted in the lower and upper extremities, respectively. All ofthe blood count; the levels of urea, creatinine, electrolytes, andplatelets; the activated partial thromboplastin time; and the interna-tional normalized ratio were within normal limits, as was the clottingtime. Our patient had no history of systemic illness (hypertension,diabetes, or malignancy) and was not taking any drug. His bloodpressure was 145/85 mm Hg, slightly higher than normal.

Cervical magnetic resonance imaging (MRI) revealed a solid lesionin the posterior epidural space, compressing the C5–T1 region of thespinal cord at the right posterior level. The lesion was slightlyhyperintense on T1–T2-weighted imaging (Fig. 1) and did not exhibitcontrast enhancement. T1-weighted axial imaging showed that spinalcord compressionwasmore pronounced on the right side. The patientbegan to improve soon after diagnosis of SSEH, and MRI (Fig. 2) andcomputed tomography (CT) (Fig. 3) performed 48 h later revealedthat both the clinical and radiological findings had significantlyregressed. The patient remained in hospital for 1 more day and was

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then discharged with a follow-up plan. No abnormality was notedupon follow-up.

SSEH is a very rare cause of neck pain [3]. Although most casespresentwith acutemyelopathy or radiculopathy, chronic cases are alsoencountered [4,5]. The clinical presentation usually features sudden-onset neck pain with accompanying motor or sensory deficits [6]. Insome cases, the Sfinker dysfunction or the Brown-Sequard syndromemay be noted [7]. Such clinical findings are not SSEH-specific; rather,they are associatedwith a number of different pathologies. Thus, SSEHcannot be diagnosed using clinical data alone [8].

MRI, myelography, and CT are used to diagnose spinal epiduralhematomas. CT shows an epidural bleed as a hyperdense mass and isof limited utility in terms of differential diagnosis. Similarly, CT datacannot be used to determine when bleeding commenced. MRI affordsa superior diagnostic capability. Sagittal MRI clearly identifies theupper and lower borders of an epidural hematoma [8] and determineswhether the hematoma is located in the anterior or posterior regionand whether cord compression is in play [9].

SSEH is usually treated via decompression surgery, commonlyfeaturing hematoma evacuation and decompressive laminectomy [2].Patients in whom neurological deficits do not develop, and whoseclinical signs are stable, may be followed up without surgicalintervention. Although reports of spontaneous resolution are veryrare, a few such patients have been described [3], but all had onlymildneurological symptoms. Our patient developed severe paraplegia but,nonetheless, experienced spontaneous recovery within 48 hours.

Diagnosis and treatment of SSEH remain controversial becausevery few cases have been reported. Such patients often present toemergency rooms and are diagnosed with the aid of MRI and CT.Surgery is often immediately performed. However, our patientrecovered rapidly and spontaneously. Clinical and radiologicalfollow-up is required prior to surgery in such patients, and a surgicaloption should be rapidly available if the condition deteriorates.

Ramazan BuyukkayaDepartment of Radiology

School of Medicine, Duzce UniversityDuzce, Turkey

E-mail address: rbuyukkaya@gmail.com

Ömer AydınBahattin Hakyemez

Department of RadiologyUludag University, School of Medicine

Bursa, Görükle 16285, Turkey

Fig. 1. T2 (A) and T1 (B) sagittal MR imaging reveal a slightly hyperintense acute hematoma at the C5–T1 level (arrow). Axial MR imaging shows bleeding into the right posterior andepidural spaces (arrow), and significant spinal cord compression (*) (C and D).

291.e2 R. Buyukkaya et al. / American Journal of Emergency Medicine 32 (2014) 291.e1–291.e3

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Dogan SereDepartment of Neurosurgery

Uludag University School of MedicineBursa, Görükle 16285, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.10.019

eferences

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] Marinella MA, Barsan WG. Spontaneously resolving cervical epidural hematomapresenting with hemiparesis. Ann Emerg Med 1996;27:514–7.

Fig. 2. Axial T2-weighted MRI performed 48 hours after admission shows that bleedinginto the epidural space has significantly decreased (arrowhead) and spinal cordcompression had disappeared.

Fig. 3. Axial CT performed 48 hours after admission shows a minimally hyperdenseacute hematoma in the epidural space (arrow).

291.e3R. Buyukkaya et al. / American Journal of Emergency Medicine 32 (2014) 291.e1–291.e3

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