Spontaneous spinal hematomas: A case series.

PURPOSE: Spontaneous spinal hematoma (SSH), a rare neurological disorder, demands immediate diagnostic evaluation and intervention to prevent lasting deficits. This case series analyzes instances, particularly highlighting cases where vascular causes were identified despite inconclusive initial imaging. METHODS: In a retrospective study of 20 patients treated for SSH at a Level I spine center from 01/01/2017 to 11/15/2023, we examined demographics, clinical presentation, imaging, and treatment details. Excluding traumatic cases, we present 4 instances of SSH associated with diverse vascular pathologies. RESULTS: Patient ages ranged from 39 to 85 years, with a median age of 66 years. 45% were male, and 55% were female. Among 20 cases, 14 were epidural hematomas, 4 subdural, 1 combined epidural and subdural, and 1 subarachnoid hemorrhage. 85% presented with neurological deficits, while 3 solely had pain-related symptoms. 55% were under anticoagulant medication, and vascular anomalies were found in 25% of cases. The cause of SSH remained unclear in 20% of cases. MRI was performed for all patients, and DSA was conducted in 25% of cases. The 4 highlighted cases involved individuals with distinct vascular pathologies managed surgically. CONCLUSION: Urgent attention is crucial for SSH due to possible lasting neurological consequences. The study emphasizes comprehensive diagnostics and surgical exploration, especially in cases with unclear etiology, to identify and address vascular causes, preventing hematoma progression or recurrence. Despite their rarity, vascular malformations contributing to spinal hematomas warrant particular attention.

Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review.

BACKGROUND: Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation. METHODS: PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment. RESULTS: We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%). CONCLUSIONS: Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.

An Unusual Case of Acute Scrotal Pain.

Patients frequently present to the emergency department with complaints of scrotal or testicular pain. Generally, there is an algorithmic approach to workup, which includes assessment for torsion, infection, or vascular causes, and musculoskeletal causes of pain are also sometimes considered. Spinal cord pathology, however, is less often explored as a cause of testicular pain. Here, we present a case of a 45-year-old man with end-stage renal disease and hypertension who presented with acute testicular pain. After a comprehensive workup, however, the source of pain was not initially found. Progression of the patient's symptoms led to the diagnosis of spontaneous spinal subdural hematoma. This atypical presentation of a rare diagnosis is also interesting due to the patient's concomitant diagnosis of an otherwise asymptomatic COVID-19 infection. While our case represents an atypical combination of clinical features, it also illustrates the importance of continued vigilance and ongoing workup when patients present with severe pain and unclear causes of their symptoms.

Spontaneous Spinal Intramedullary Hematoma in an Infant: A Rare Entity and a Diagnostic Challenge.

INTRODUCTION: Spontaneous spinal intramedullary hematoma is a rare cause of acute paraplegia in adults and is extremely uncommon in children. Very few cases with no apparent etiology (such as trauma, vascular lesions) have been reported in adults. We did not find any apparent cause for the hematoma in our patient and to the best of our knowledge, this is first case reported in infants. CASE REPORT: We present the case of a 6-month-old female child admitted with acute-onset paraplegia, bladder bowel involvement, and no history of trauma or bleeding diathesis. The MRI showed an intramedullary mass extending from the D11-L1 level. The mass was excised and histopathology revealed it to be an organizing hematoma. CONCLUSION: Our case highlights that though it is a rare entity, there is a need for more awareness when dealing with children with sudden paraplegia, acute retention of urine, or neurological deficit. Early diagnosis and prompt surgery are crucial to achieve the best neurological outcome.

Spinal Epidural Hematoma Post Evacuation of Spontaneous Spinal Intradural Hematoma.

BACKGROUND: Spinal hematomas are rarely associated with dengue syndrome and usually occur at the time of active dengue fever. Late presentation after recovery from dengue fever, intradural hematoma, presentation as a multiloculated cystic lesion with longitudinal extensive myelitis, and recurrence after surgery are rarely or not described. Due to the peculiar association of all these findings, we report this case to provide insight into the existence of such a rare presentation. CASE DESCRIPTION: A 79-year-old-male developed sudden-onset paraparesis after 1 week of recovery from dengue fever. The blood counts were normal. Magnetic resonance imaging of the thoracic spine was suggestive of intradural hematoma. The patient underwent emergency decompression and drainage of hematoma with recovery in the neurologic status over the next few weeks. He presented to our emergency department after 5 weeks of the first surgery with deterioration in the neurologic status to complete paraplegia. Repeat magnetic resonance imaging showed a posterior epidural collection bulging anteriorly, causing cord compression. The patient was reoperated on by decompression. There was no neurologic recovery. The patient was managed with multidisciplinary rehabilitation, and he was independent in most of the activities at the time of discharge. CONCLUSIONS: Spinal hematoma should be kept in mind in patients who present with neurologic complications after dengue fever. It can have an atypical radiologic presentation and may present with recurrent hemorrhage after surgery. Attention should also be given to delayed presentation of neurologic complications, which may develop even after weeks of recovery from dengue fever.

Rare Presentations of Spontaneous Spinal Epidural Hematomas in Children.

Spontaneous spinal epidural hematomas are a rare presentation in children with very few case reports of spontaneous spinal hemorrhage in the pediatric age-group. There has to be a high index of suspicion of spontaneous spinal bleed in patients with acute-onset quadriparesis with no prior history of bleeding or trauma, as early diagnosis and surgical decompression is associated with better neurological outcomes.

Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review.

BACKGROUND: Spinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain. Although spontaneous SHs have been described in the setting of anticoagulation with warfarin or enoxaparin, few cases of spontaneous SH on direct oral anticoagulants (DOACs) have been reported. CASE REPORT: We report a case of spontaneous spinal epidural hematoma in a patient on rivaroxaban. A 72-year-old man on rivaroxaban and aspirin presented with a 4-day history of nontraumatic back pain. In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11-L2. The patient underwent emergent decompression and hematoma evacuation and was discharged home 8 days later with complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and surgical intervention for SHs with neurologic compromise is key to favorable outcome. Optimal timing of surgery in patients on DOACs requires an assessment of the risk of intraoperative or postoperative bleeding, an assessment of the patient's symptom progression, as well as an understanding of the pharmacokinetics of the DOAC used and possible reversal options available. We also review all published cases of spontaneous SHs in patients on DOACs and report on their management and outcomes.

Spontaneous ventral spinal epidural hematoma in a child: A case report and review of literature.

Spontaneous spinal epidural hematoma is very uncommon cause of spinal cord compression. It is extremely rare in children and is mostly located in dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is even rarer, with only four previous reports in childrens. We are reporting fifth such case in a 14 year old male child. He presented with history of sudden onset weakness and sensory loss in both lower limbs with bladder bowel involvment since 15 days. There was no history of trauma or bleeding diasthesis. On clinical examination he had spastic paraplegia. Magnetic resonance imaging (MRI) of dorsal spine was suggestive of ventral spinal epidural hematoma extending from first to sixth dorsal vertebrae. Laminectomy of fourth and fifth dorsal vertebrae and complete evacuation of hematoma was done on the same day of admission. Postoperatively the neurological status was same.