Subacute cervical epidural hematomas

Subacute cervical epidural hematomas

414 ELSEVIER Subacute Cervical Epidural Hematomas J.P. Farias, M.D., J. Almeida Lima, M.D., and J. Lobo Antunes, M.D. Department of Neurosurgery, Ho...

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Subacute Cervical Epidural Hematomas J.P. Farias, M.D., J. Almeida Lima, M.D., and J. Lobo Antunes, M.D. Department of Neurosurgery, Hospital de Santa Maria, Lisbon, Portugal

Farias JP, Almeida Lima J, Lobo Antunes J. Subacute cervical epidural hematomas. Surg Neurol 1994;42:414-6.

The authors report two cases of cervical epidural hematomas with atypical subacute clinical presentation; both were operated on with excellent results. The literature is reviewed and the etiologic factors, clinical presentation, diagnosis, and therapy are discussed. It is concluded that the clinical presentation and evolution of cervical epidural hematomas are more variable than previously described, including slow evolving forms and even cases with spontaneous resolution. Magnetic resonance imaging is the diagnostic procedure of choice. Early surgical decompression and evacuation of the lesion is the indicated therapy in most cases. KEY WORDS: Cervical spine; Spinal cord compression; Spinal epidural hematoma; Spine trauma

Cervical epidural hematomas are rare clinical entities, which have been described in association with spine trauma, coagulopathies, anticoagulation, arteriovenous malformations, vertebral angiomas, and spinal neoplasms. In the absence of significant trauma or other discernible cause, they have been described as spontaneous [2,8]. Their presentation and clinical evolution are variable, but their functional and even vital prognosis without surgical decompression are considered poor, although spontaneous resolution of the neurologic deficit and hematoma have been reported recently [3,10]. W e are reporting two cases of cervical epidural hematoma in elderly patients, with atypical presentation and subacute evolution, diagnosed by computed tomography (CT) and magnetic resonance imaging (MRI) scans, and operated upon with excellent results. Case R e p o r t s

Case 1 A 75-year-old white woman was admitted to the Neurosurgical Department in April 1992 with a 2-week Address reprint requests to: J.P. Farias, M.D., S. Neurocirurgia, Hospital de Santa Maria, Av. Prof. Egas Moniz, 1600, Lisboa, Portugal. Received March 29, 1994; accepted May 12, 1994.

© 1994 by ElsevierScienceInc.

history of minor cervical trauma, followed by persistent moderate cervical pain. On the day of admission, she felt a sudden increase in cervical pain and noticed a sudden appearance of paresthesias in both arms and weakness in the left upper extremity. The examination revealed painful palpation of the spinous processes of C3 to C5 vertebrae. The neurologic examination demonstrated weakness of abduction and flexion of the left upper extremity, hypesthesia of the left shoulder and external aspect of the left arm, and abolition of the bicipital and radial deep tendon reflexes. Cervical x-rays did not show any evidence of trauma. CT scan was immediately performed (Figure 1), which showed an intraspinal spontaneously hyperdense lesion, on the left posterior side, pushing the spinal cord anteriorly and to the right, between the C2 and C4 vertebral segments. The patient's clinical condition improved over the next 48 hours with steroid therapy (dexamethasone 4 mg q6h) and cervical immobilization. The motor deficit improved, but the intensity of the cervical pain and paresthesias did not change. MRI of the spine was then performed and was consistent with an epidural hematoma (Figure 2). Laminectomy of C2 and C3 and removal of the hematoma were then performed. The pain and paresthesias disappeared immediately, and the patient was discharged symptom-free on the sixth postoperative day.

Case 2 A 76-year-old white woman presented suffering from poorly controlled hypertension noticed in December 1991 and a sudden and intense nuchal pain while lifting a weight. Over the next 48 hours she slowly developed right hemiparesis and left hemihypesthesia. She sought medical help on the third day after the initial complaints, and when first examined she had a Brown-SSquard syndrome with right hemiparesis and left hemihypesthesia below the level of the C4 dermatome. MRI was then performed and revealed a right posterior epidural hematoma at the C4 vertebral level (Figure 3). Laminectomy of C4 and removal of the hematoma were performed, with complete resolution of the neurologic deficit within 4 days. 0090-3019/94/$7.00

Subacute Cervical Epidural Hematomas

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Figure 1. Case 1: C T scan of the cervical spine at the level of C3 demonstrating an area of spontaneous hyperdensity (arrow). Discussion Cervical epidural hematomas are associated with spine trauma, coagulopathy, anticoagulation, arteriovenous malformations, vertebral angiomas, and neoplasms. In the absence of such factors they are considered spontaneous. Beatty and Winston [2] include in this group the cases with minor spine trauma without fracture, dislocation, or ligamentous disruption. Traumatic spinal epidural hematomas are classically associated with vertebral body or posterior arch fractures. Spontaneous spinal epidural hematomas have been described after minor physical strain, Valsalva maneuvers (cough, sneeze, defecation), or brisk cervical movements. In some cases the initial symptoms appeared during rest or sleep periods.

Figure 2. Case 1: M R I Tl-weighted sagittal view revealing a dorsal hyperintense collection compressing the spinal cord (arrow).

Figure 3. Case 2: M R I Te-weighted sagittal view showing a narrow spinal canal and a hyperintense dorsal lesion (arrow). In case 1, the probable etiologic factors was traumatic, although no fracture, dislocation, or ligamentous disruption was demonstrated. Case 2 should be considered of the spontaneous variety, although arterial hypertension may have been a contributing factor. Until recently, epidural veins were considered the source of hemorrhage in spinal epidural hematomas, because arteries in the spinal epidural space were considered scarce. Beatty and Winston suggested the spinal epidural arteries as the hemorrhage source. They based their view on the studies of Crock and Yoshizawa [5] on the blood supply of the vertebral column and spinal cord, which showed a spinal epidural arterial net much more developed than previously thought, and in the fact that, intraspinal venous pressure, being inferior to intrathecal pressure, should not significantly compress the spinal cord in case of hemorrhage. Traumatic spinal epidural hematomas classically present with a progressive neurologic deficit after a free interval of a few hours following the traumatic event, associated with vertebral body or posterior arch fractures. The cases of spontaneous spinal epidural hematomas reported in the literature also have a rather uniform presentation: sudden interscapular or cervical pain with superior limb irradiation caused by physical strain or Valsalva maneuvers, followed in some minutes or hours

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(rarely days) by progressive paraparesis or tetraparesis. The patient's age in the cases reported in the literature range from 21 months to 79 years, and there is no significant sex difference. The most frequent localization is the low cervical and/or high dorsal regions. The prognosis was considered until recently uniformly fatal without early surgery, with the postsurgical mortality in the group of patients with rapidly progressive evolution (minutes to hours) being 21% [2]. Presently the surgical results are much better in the majority of cases, probably due to the easier and quicker access of patients to neurosurgical centers, and to the existence of diagnostic tools such as CT and MRI scans, which allow earlier diagnosis and treatment. Recently some cases of traumatic and spontaneous spinal epidural hematomas have been reported that had a progressive neurologic deficit in the first hours, but experienced spontaneous resolution of both the deficit and the hematoma (verified by MRI scan) without surgery [3,10]. The two cases reported here had a clinical presentation and evolution quite different from the ones referred to in the literature. In case 1 the neurologic deficit developed only 2 weeks after the initial cervical trauma, and consisted of radicular symptoms with no spinal cord dysfunction, and partially recovered in the following 48 hours. CT and MRI scans did not show any traumatic lesions apart from the hematoma itself. In case 2, although the initial presentation was typical, the neurologic deficit was partial and slowly progressive. High cervical epidural hematomas (confined above the C5 vertebral level) are rare, especially spontaneous ones. Only two such cases have been reported in the literature, and both have died [2,9]. It should be emphasized therefore that the clinical picture of cervical epidural hematomas is more variable than previously described, including not only acute rapidly progressive forms, but also subacute slow evolving presentations with partial neurologic deficit, sometimes waxing and waning in severity, and even with spontaneous resolution. Diagnosis of traumatic spinal epidural hematomas relies on their demonstration by CT or MRI scans. MRI scan is the diagnostic procedure of choice [10], because

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it is capable of detecting other associated traumatic lesions such as ligamentous disruption, bone compression, herniated vertebral disc, cord edema or hemorrhage, and subdural or subarachnoid hemorrhage. Differential diagnosis of spontaneous spinal epidural hematomas includes acute herniated vertebral disc, epidural tumor or abscess, spondylitis, transverse myelitis, or even aortic dissection. Again, MRI scan is, undoubtedly, the diagnostic procedure of choice. W e believe early surgical decompression is the treatment of choice even in elderly patients such as ours. A conservative treatment option should be reserved for exceptional situations with minimal deficits, or clear contraindication for surgery. Close monitoring of such patients is obviously required.

References 1. Avrahami E, Tadmor R, Ram Z, Feibel M, Itzhak Y. MR demonstration of spontaneous acute epidural hematoma of the thoracic spine. Case reports. Neuroradiology 1989;31:89-92. 2. Beatty RM, Winston KR. Spontaneous cervical epidural hematoma. J Neurosurg 1984;6:143-8. 3. Clarke DB, Bertrand J, Tampieri D. Spontaneous spinal epidural hematoma causing paraplegia: resolution and recovery without surgical decompression. Neurosurgery 1992 ;30:108-11. 4. Cooper DW. Spontaneous spinal epidural hematoma. Case report. J Neurosurg 1967;26:343-6. 5. Crock HV, Yoshizawa H. The blood supply of the vertebral column and spinal cord in man. Berlin/Heidelberg/New York: Springer-Verlag, 1977. 6. Cube HM. Spinal extradural hemorrhage. J Neurosurg 1962;19:171-2. 7. Grollmus J, Hoff J. Spontaneous spinal epidural haemorrhage: good results after early treatment. J Neurol Neurosurg Psychiatry 1975;38:89-90. 8. Lepoire J, Tridon P, Montant J, et al. L'hSmatome extradural rachidien spontan~. Neurochirurgie 1961;7:298-313. 9. Markham JW, Lynge HN, Stahlman GEB. The syndrome of spontaneous spinal epidural hematoma. Report of three cases. J Neurosurg 1967;26:334~42. 10. Pan G, Kulkarni M, MacDougal DJ, Miner ME. Traumatic epidural hematoma of the cervical spine: diagnosis with magnetic resonance imaging. Case report. J Neurosurg 1988; 68:798-801. 11. Vall6e B, Besson G, Gaudin J, et al. Spontaneous spinal epidural hematoma in a 22-month-old girl. J Neurosurg 1982; 56:135-8.