Risk factors for spinal subdural hematoma after minimally invasive transforaminal lumbar Interbody Fusion (MI-TLIF): a multivariate analysis.

BACKGROUND: Spinal subdural hematoma (SSH) is a rare cause of compression of the neutral elements of the spinal cord. However, little is known about the presentation of acute SSH after lumbar spine surgery. The reason for this may be that symptomatic SSH occurs rarely and is not given enough attention by spine surgeons. Currently, the decision to perform MRI postoperatively is more dependent on surgeon preference; therefore, no high-quality studies have been published. Our team reports our experience in the diagnosis and management of SSH after lumbar decompression and fusion surgery. METHODS: We retrospectively studied 215 patients who underwent routine MRI following minimal invasive transforaminal lumbar interbody fusion (MI-TLIF) between 2020-01-01 and 2022-06-30. The patients were divided into SSH group (17 cases) and non-SSH group (198 cases) according to the occurrence of SSH. Univariate analysis and multivariate logistic regression analysis were performed to identify relevant risk factors that increase the risk of SSH postoperatively. RESULTS: None of the patients presented with serious neurologic symptoms, such as lower extremity paralysis or cauda equina syndrome that required emergency hematoma debridement. SSH was found in 17 (7.9%) patients and non-SSH in 198 (92.1%). Factors affecting SSH were presence of hypertension, presence of diabetes and postoperative anticoagulant therapy. The significantly independent risk factor of postoperative SSH were diabetes (P = 0.008, OR: 6.988) and postoperative anticoagulant therapy (P = 0.003, OR: 8.808). CONCLUSIONS: SSH after MI-TLIF is not a rare condition, with generally no requirement of emergency evacuation. Comprehensive anti-symptomatic treatment could achieve satisfactory results. Diabetes mellitus and postoperative anticoagulant therapy are independent risk factors for SSH. Spine surgeons should hold applicability of the use of anticoagulants after lumbar surgery.

Spinal subdural hematoma in a patient with immune thrombocytopenic purpura following microvascular decompression: a rare case report.

This article reports a case of spontaneous spinal subdural hematoma (SSDH) after brain surgery in a patient with immune thrombocytopenic purpura (ITP), reviews the relevant literature, and discusses the etiology, pathogenesis, and clinical features of SSDH in patients with ITP. A male patient in his early 50 s with an 8-year history of ITP and suffering from coexistent hemifacial spasm and trigeminal neuralgia underwent microvascular decompression in our department. His preoperative corrected platelet count was within the normal range. On postoperative day 2, the patient complained of acute low back pain and sciatica. Lumbar magnetic resonance imaging demonstrated an SSDH extending from L3 to L4 with a significantly decreased platelet count (30.0 × 109/L). The pain was gradually relieved after 2 weeks of conservative treatment, and no neurological deficit occurred during the 1-year follow-up. Brain surgery may increase the risk of postoperative SSDH in patients with ITP. Clinicians planning brain surgery must conduct a rigorous assessment through detailed physical examination, laboratory tests, and medical history records and maintain perioperative platelet counts within the normal range to prevent various risks associated with spinal cord compression.

Non-iatrogenic spontaneous acute spinal subdural haematoma after transforaminal lumbar interbody fusion.

PURPOSE: Reporting a rare case of a non-iatrogenic spontaneously resolved spinal subdural haematoma (SSDH) following revision of transforaminal lumbar interbody fusion (TLIF) and its possible explanation. METHODS: Case report of a 40-year-old man with a history of persistent lower back and left lower extremity radicular pain, secondary to recurrent disc prolapse, lumbar spondylosis with foraminal stenosis. He underwent an L5/S1 transforaminal interbody fusion via a right sided approach (through previous lumbar microdiscectomy incision). On post-operative day two, the patient developed headache and photophobia that were discovered to be secondary to an acute thoracolumbar subdural haematoma with no objective neurological deficit. RESULTS: After close observation of his neurological status and conservative management of the subdural haematoma, the patient fully recovered from his symptoms and remained problem-free at 2-year follow-up. CONCLUSIONS: Although the occurrence of acute spinal subdural haematoma after spinal surgery is a rare complication following spinal surgery, its appropriate management relies on early recognition if significant morbidity is to be avoided.

Cranial subdural migrating to lumbar subdural space in a toddler.

Migrated spinal subdural haematoma (sSDH) is a significantly uncommon finding. This case involves a paediatric patient representing after cranial trauma with new abnormal gait and leg pain who was found to have a migrated sSDH. Literature review for reported cases of pathogenesis theories, causes and management was performed and summarised in this report. The authors concluded that new abnormal gait and leg pain in a paediatric patient with previous cranial trauma is an indication for spinal MRI if migrated subdural haematoma is suspected. Non-surgical management is generally tolerated, and steroids can be trialled for radiculopathy if clinically indicated.

SPINAL SUBDURAL HEMATOMA ASSOCIATED WITH LUMBAR PUNCTURE - A CASE REPORT.

Spinal subdural hematoma caused by lumbar puncture is a rare state of acute blood clot in spinal subdural space, and in some cases, it can be the cause of local compression and consecutive neurological symptoms. We present a 36-year-old female patient who was hospitalized due to persistent headache despite pharmacological therapy. Therefore, we performed lumbar puncture in order to measure intracranial pressure and evaluate cerebrospinal fluid. After lumbar puncture, the patient was complaining of pain in the lumbar region. Emergency magnetic resonance imaging (MRI) of the lumbosacral (LS) region was performed to show acute subdural hematoma of up to 7.3 mm in the dorsal part of the spinal canal at the level of L1 vertebra to the inferior endplate of L4 vertebra. Repeat LS MRI after 3 hours showed unchanged finding. The patient reported gradual regression of pain in the LS region over the next few days, therefore conservative treatment was applied. Patients with a previously known blood clotting disorder and patients on anticoagulation therapy have worse outcome as compared with patients without such disorders. During treatment, it is necessary to monitor patient clinical state and consider the need of surgical treatment.

Spinal Subdural Hematoma: Rare Complication of Spinal Decompression Surgery.

OBJECTIVE: Spinal subdural hematoma (SSH) is a rare and infrequently reported complication of hemilaminectomy, laminectomy, and other spinal decompression surgeries. In this review, we aim to analyze the available literature for reported cases of SSH to better identify risk factors and presenting symptoms, as well as highlight the importance in prompt investigation and management of SSH to prevent long-term morbidity and chronic neurologic deficit. METHODS: A review of the medical literature was undertaken using search terms hemilaminectomy OR laminectomy AND spinal subdural haematoma. All identified reports were screened for language, adult population, and human studies. Report abstracts were screened for relevance to question, with SSH occurring postoperatively following hemilaminectomy or laminectomy included. Four reports were included in the review. CONCLUSIONS: SSH is a rare, emergency condition with neurologic deficit that can present as recurrent back pain and acute cauda equina postoperatively following hemilaminectomy and laminectomy procedures. Vigilance, early investigation, and surgical evacuation is important in preventing short- and long-term morbidity. Further collation of data and analysis is required to better identify patients at high risk for developing SSH postoperatively.

Iatrogenic intra-spinal subdural haematoma: An exceptionally rare phenomenon.

Spinal subdural haematoma (SSDH) is very rare but potentially life debilitating spinal vascular condition, often developing acutely. Usually managed conservatively but may require immediate evacuation to prevent potential harm to the spinal cord. Predisposing factors can be spontaneous or iatrogenic. MRI remains the modality of choice to diagnose and see the age and extent of haemorrhage. We hereby present the case of a young child who developed iatrogenic spinal subdural haematoma.

Spinal subdural hematoma and subdural anesthesia following combined spinal-epidural anesthesia: a case report.

BACKGROUND: Subdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal-epidural anesthesia. CASE PRESENTATION: A 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34+ 5 weeks underwent cesarean delivery. Routine combined spinal-epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal. CONCLUSIONS: All anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.

Dorsal subdural hemorrhage from ruptured thoracic radicular artery pseudoaneurysm. case report and surgical video.

Radiculomedullary artery malformations are rare conditions: their rupture usually manifests with subarachnoid hemorrhage. To the best of our knowledge no cases of subdural bleeding have been described in the literature. We present the rare case of a 74 year old woman admitted to our Institute with sudden onset of right lower limb motor deficit and hypoesthesia, with no history of trauma: Magnetic Resonance Imaging of the dorsal spine was performed and a subdural hematoma was detected; subsequent dorsal laminectomy for hematoma evacuation was carried out. As the source of bleeding was not recognized, Digital Subtraction Angiography (DSA) was performed: a new leak of contrast agent from a dilation of a spinal radicular artery at the level of T5 was detected; XperCT imaging (an angiographic acquisition of Computed Tomography-like images) confirmed a new acute subdural bleeding. Urgent repeat surgery was considered the best option to identify and close the malformation. Postoperative DSA confirmed complete exclusion of the radicular artery malformation. This is the first report that describes, with an intraoperative video, a case of radiculomedullary artery pseudoaneurysm, responsible of an acute subdural bleeding and associated neurological deficit.

Lumbosacral subdural hematoma associated with cranial subdural hematoma and craniocerebral surgery: Three cases and a systemic literature review.

OBJECTIVE: The authors aim to focus on lumbosacral subdural hematoma (SDH) associated with cranial subdural hematoma and craniocerebral surgery, which has been rarely reported. MATERIAL AND METHODS: They present 3 cases of lumbosacral SDH, including 2 associated with cranial chronic SDH and 1 following craniotomy for neck clipping of cerebral aneurysm. Using a PubMed search, they also provide a systemic literature review to summarize pathogenesis, treatment and outcome. RESULTS: All cases presented with bilateral radiating leg pain, and recovered completely by conservative managements. Predisposing factors were trauma, anticoagulant therapy and brain atrophy. Literature review revealed 54 such cases, in which 28 cases associated with cranial SDH and 26 cases associated with craniocerebral surgery. In both group, main symptoms were low back and radiating leg pain, and sensorimotor deficits. Regardless of treatments, conservatively or surgically, outcome was favorable. Migration of cranial hematoma is most supported pathogenesis, while intracranial hypotension due to cerebrospinal fluid overdrainage procedures may also be a contributing factor for cases associated with craniocerebral surgery. CONCLUSIONS: Lumbosacral SDH should be considered in patients present with unexpected low back and radiating leg pains associated with cranial SDH and craniocerebral surgery. Conservative treatment would be reasonable for cases with mild symptoms as the first treatment of choice.

An Acute Spinal Intradural Hematoma after an Extraforaminal Wiltse Approach: A Case Report and Review of the Literature.

A nontraumatic spontaneous spinal acute subdural hematoma (sSDH) is a rare complication after spinal surgery. Although an sSDH is often associated with anticoagulation therapy, vascular malformations, or lumbar puncture, the pathogenesis of nontraumatic spontaneous sSDH remains unclear. We present the case of an intradural hematoma after an extraforaminal surgery through the Wiltse approach for an extraforaminal disk herniation at L5/S1. This 58-year-old woman experienced hypoesthesia and progressive motor dysfunction in the left leg several hours postoperation. Urgent magnetic resonance imaging revealed an intradural hematoma at the L1/L2 to L2/L3 level in the ventral dural sac proximal to the surgical level. Surgical decompression was performed. There was no evidence of trauma, coagulopathy, or anticoagulation therapy. To our knowledge, this case is the first to report an acute sSDH proximal to the surgery level after an extraforaminal spinal surgery through the Wiltse approach for an extraforaminal disk herniation. It illustrates that attentive postoperative neurologic monitoring, even in the absence of intraoperative irregularities, remains important to diagnose and treat this complication at the early stage.

Delayed Development of Spinal Subdural Hematoma Following Cranial Trauma: A Case Report and Review of the Literature.

BACKGROUND: Spinal subdural hematomas (SDHs) have been reported secondary to direct trauma or iatrogenic causes associated with coagulopathies. Spinal SDHs found after the development of acute intracranial SDHs, without any evidence of trauma to the spine, are extremely rare. In addition to this rare presentation, there is a lack of consensus regarding whether surgical decompression is the ideal treatment strategy. Depending on the extent of SDH within the spinal canal, surgical decompression may be difficult where diffuse hematoma within the intradural space requires multilevel decompression for treatment. CASE DESCRIPTION: A 46-year-old man initially presented with an acute cranial SDH following isolated head trauma. After a period of full recovery, he developed delayed lower extremity paraparesis secondary to the formation of a thoracolumbar SDH. This hematoma coincided with resolution of the cranial SDH and likely was due to redistribution of blood from the cranial subdural space into the spinal canal. Given the diffuse multilevel nature of the spread of hematoma and lack of a focal area of compression, he was managed conservatively. He demonstrated small signs of neurologic improvement over several days and regained considerable strength over the following several weeks. CONCLUSIONS: This report demonstrates a very rare occurrence of a traumatic intracranial SDH migrating into the thoracic and lumbar spine. This case also highlights that despite acute neurologic deficits, conservative management may be a feasible strategy that can result in recovery of neurologic function.

Spinal Subdural Hematoma owing to the Removal of Cerebrospinal Fluid Drainage Tube During Thoracic Endovascular Aortic Repair.

BACKGROUND: Cerebrospinal fluid (CSF) drainage during the treatment of aortic disease is commonly performed to prevent spinal cord ischemia. Spinal subdural hematoma (SDH) has never been reported after CSF drainage during thoracic endovascular aortic repair (TEVAR). We present a case of concurrent intracranial subarachnoid hemorrhage (SAH) and spinal SDH after CSF drainage tube removal in a patient with TEVAR. CASE DESCRIPTION: A 73-year-old man was hospitalized to undergo TEVAR. The day before the procedure, a lumbar CSF drainage tube was inserted. Continuous CSF drainage was performed only during the procedure, and the tube was removed the following day. The patient complained of mild back pain on postoperative day 2; headache, bilateral lower limb paresis, and bladder and rectal disturbances developed on postoperative day 5. Brain and spinal magnetic resonance imaging revealed spinal subdural or subarachnoid hematoma and intracranial SAH. Lumbar laminectomies for spinal SDH removal were performed; lower limb strength improved immediately after surgery. At postoperative 2 years, the patient returned to his preoperative activity level; only mild right lower limb numbness persisted. CONCLUSIONS: We present a rare case of intracranial SAH and spinal SDH that developed after CSF drainage tube removal in a patient with TEVAR. CSF drainage should be carefully considered in patients undergoing aortic procedures, as SAH and spinal SDH may occur in addition to spinal cord ischemia.

Spontaneous Spinal Subdural Hematoma after Percutaneous Mechanical Thrombectomy Combined with Catheter-Directed Thrombolysis for Deep Venous Thrombosis: A Case Report.

BACKGROUND: Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis is one of the most important methods for deep venous thrombosis treatment. Spontaneous spinal subdural hematoma is a remarkably rare complication in the thrombolysis process with catastrophic consequences, as shown in this case report. METHODS: Percutaneous mechanical thrombectomy, percutaneous angioplasty, and catheter-directed thrombolysis were performed for the patient. Postoperatively, the patient was diagnosed with spontaneous spinal subdural hematoma and received a series of medical treatments and surgical interventions. RESULTS: The patient was still paraplegic and incontinent at the postoperative 7-month follow-up. CONCLUSIONS: Neurologic symptoms must be monitored carefully both during and after the thrombolysis procedure. The onset of spinal neurologic deficits in any patient must raise the suspicion that a spinal subdural hematoma has occurred. Surgical decompression beyond 24 hr may cause permanent neurological damage.

Myelon Stent - a New Technical Procedure to Protect the Spinal Cord Against Tumour Compression. / Myelonstent ­ eine neuartige Technik zum Schutz des Rückenmarks vor Tumorkompression.

A 59-year-old woman with breast cancer who had undergone chemotherapy, three surgical interventions at the thoracic spine, and radiation since 2012, suffered from progressive ataxia caused by a single relapse metastasis resulting in spinal stenosis at thoracic level 6. Therefore, excessive tumour debulking was performed at thoracic levels 4 to 7 and a fully covered, self-expandable stent was placed around the spinal cord at these levels in order to create a mechanical barrier and to prevent the spinal cord from compression by the tumour. Neuromonitoring was performed before, during, and after surgical procedure. Clinically and electrophysiologically, ataxia appeared improved after intervention. Radiologically, no tumour growth was found at thoracic levels 4 to 7 after the intervention.

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.

Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature.

OBJECTIVE: Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH. METHODS: A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case. RESULTS: Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH. CONCLUSION: S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.

Acute Lumbar Spinal Subdural Hematoma Inducing Paraplegia After Lumbar Spinal Manipulation: Case Report and Literature Review.

BACKGROUND: Traumatic spinal subdural hematoma is an extremely rare occurrence that requires urgent investigation and most often prompt intervention. To our knowledge, this is the first reported case related to a spinal manipulative therapy. CASE DESCRIPTION: This report describes a case of traumatic lumbar subdural hematoma after a spinal manipulative therapy without any predisposing factor. A 23-year-old man was admitted to the emergency department for partial cauda equina syndrome after a spinal manipulation performed by a physiotherapist. Magnetic resonance imaging showed an acute spinal subdural hematoma at L2-L3 level with cauda equina compression. The patient underwent an emergency L2 laminectomy with evacuation of the hematoma. He recovered completely his neurologic functions after 1 week. CONCLUSION: Practitioners of spinal manipulations should be aware of spinal subdural hematoma as a possible complication. A rapid diagnosis with magnetic resonance imaging is mandatory, and emergency surgical decompression is usually the optimal treatment for spinal subdural hematomas with severe neurologic deficit.

Breech delivery, rupture of Batson's plexus, T8 epidural hematoma, and paraplegia.

A male newborn born by an atraumatic vaginal frank breech delivery was noted to have normal limb movement at birth. However, at 24 hours the neonate developed paraplegia with no evidence of spinal cord injury on radiographic films. Ultrasound and MRI demonstrated an epidural hematoma at the level of T8 and distal cord edema which extended to the conus medullaris. Delayed onset paraplegia following an atraumatic vaginal breech delivery is unlikely to have been caused by acute traction or torsion at birth. Traction and torsion injuries would present acutely. This infant developed a T8 epidural hematoma which has not been reported in a newborn. The pathophysiology of a spontaneous spinal epidural hematoma (SSEH) in adults is frequently related to increased abdominal/thoracic pressure which results in increased pressure in the highly anastomotic network of thin walled and valve-less vertebral venous plexus (Batson's plexus). Such increase in abdominal/thoracic pressure could occur during a frank breech delivery and result in a slow onset epidural hematoma. This report highlights the importance of considering slow onset epidural hematoma in the differential diagnosis of neonates who develop slow onset paraplegia. If diagnosed quickly, an epidural hematoma represents a potentially treatable etiology by rapid surgical decompression.

Spontaneous intracranial hypotension due to sacral diverticula: Two-case history and a pocket-sized review.

Spontaneous intracranial hypotension is an increasingly recognized cause of atypical, secondary headaches. Nevertheless, its clinical and imaging spectrum is far from an exhaustive definition, ranging from straightforward cases with unambiguous findings and prompt response to treatment to more challenging ones, requiring advanced, more complex imaging and targeted therapies. We describe two unusual cases as a cue to draw a literature-based, practical approach to the management of the syndrome.