Delayed postoperative spontaneous spinal epidural hematoma: Case based review

Abstract

Introduction and importance

Postoperative spontaneous spinal epidural hematoma (SSEDH) is a rare complication in clinical practice. Despite its rarity, SSEDH is a critical emergency situation associated with neurological deficits, and improper or delayed management may lead to severe consequences. Therefore, surgical operators should familiarize themselves with SSEDH and give it more attention.

Case presentation

This study describes the case of an elderly woman diagnosed with a left unilateral femoral neck fracture, severe osteoporosis, and multi-segmental vertebral compression fracture. Following artificial femoral head replacement surgery, the patient developed postoperative SSEDH. Subsequently, the patient underwent surgical removal of the posterior epidural hematoma and spinal cord decompression. The postoperative recovery was favorable, with normal muscle strength and tension in both lower limbs. A 4-year follow-up showed no complications.

Clinical discussion

The occurrence of SSEDH during the perioperative period of non-spinal surgeries is relatively uncommon. However, SSEDH is a neurosurgical emergency associated with neurological deficits, and prompt surgical intervention is crucial for successful treatment.

Conclusion

Clinicians should enhance their knowledge of SSEDH and remain vigilant towards this condition. Literature review highlights the significance of factors such as aging in the development of SSEDH following non-spinal surgeries in the perioperative period.

Highlights

• •Spontaneous spinal epidural hematoma after operation is a rare but emergency circumstance.
• •Old patients who received surgical treatment have a higher incidence of thoracic spine involvement.
• •Emergency surgical interventions are necessary for hematoma removal when accompanied with neurological deficits.

1. Introduction

Spontaneous spinal epidural hematoma (SSEDH) is defined as a spinal epidural hematoma that occurs without a clear cause. Although rare, SSEDH is a medical emergency associated with neurological deficits, and any delays in diagnosis and treatment can lead to severe consequences. Therefore, surgical operators should increase their understanding of SSEDH and be vigilant in its management.

Although the etiology remains mystery, many speculations have been proposed, among which rupture of venous plexus in spinal canal predominates and have many probable triggers [1]. In this article, we report a SSEDH case occurred after artificial femoral head replacement surgery within the perioperative period and postoperative nausea is speculated to be the direct factor. Besides, we noticed that SSEDH occurring during the perioperative period of non-spinal surgery is relatively rare [2]. Hence, we present a review of literature regarding SSEDH after non-spinal surgeries within perioperative period as well.

2. Case description

The work has been reported in line with the SCARE criteria [3]. An elderly woman, aged seventy-one, was diagnosed with a left unilateral femoral neck fracture accompanied by severe osteoporosis and multi-segmental vertebral compression fracture. Preoperative assessments were conducted, and physical examinations showed no abnormalities. The patient had no history of anticoagulation therapy. She underwent artificial femoral head replacement surgery under epidural anesthesia. On the first day post-operation, she experienced poor appetite and nausea. The following day, neurological deficits emerged, including sensory decline, loss of proprioception, bilateral toe extension muscle strength of 2/5, the rest of the muscle strength at 0/5, disappearance of abdominal wall reflex, and absent knee and ankle reflexes below T7 level. Delayed spinal epidural hematoma was suspected, and urgent magnetic resonance imaging (MRI) revealed the presence of an epidural hematoma at the T3-L2 level (Fig. 1). Emergency surgical evacuation of the hematoma was performed under local anesthesia and intensification (Fig. 2). The postoperative recovery was favorable, with normal muscle strength (5/5) and tension in both lower limbs. A 4-year follow-up after surgery showed no complications and excellent outcomes with complete resolution.

Fig. 1.

Two consecutive T1-weighted sagittal MRI showing the formation of epidural hematomas.

Fig. 2.

Multiple active bleeding venous plexus were identified (black arrows) during the operation in T3 to L2 level.

3. Review of literatures

A literature review of published articles was searched via PubMed up to August 16, 2023 to collect cases of SSEDH after non-spinal surgery. Any duplicates, inaccessible articles and non-English articles were excluded. All published articles were reviewed to ensure missing potential cases. All authors reviewed all articles.

There were eleven cases of SSEDH in the postoperative period of non-spinal surgery. Detailed information of precedented cases as well as our case was listed in Table 1. Except for two postpartum patients (31 and 23 years old respectively), most cases are the elder (55–90 years old). We recorded the type of non-spinal surgery of these cases. SSEDH in all cases were located in cervical or thoracic level of spinal canal and only two of them affected the ventral side while the other only involved the dorsal side. Five cases definitely stated the usage of epidural or spinal anesthesia during the non-spinal operation. Ten paroxysms happened within three days after the non-spinal surgery and all occurred within ten days. Besides, the onset symptoms of each case were also recorded and we try to record the laboratory test results if possible.

Table 1.

Previous reports of patients with delayed postoperative spontaneous spinal epidural hematoma.

Reference	Age (years)	Gender	Probable trigger	Surgical operation	Other medical history	Level of SSEDH	Probable onset time after operation	Onset symptoms	Laboratory tests	Anesthesia
Luo et al., 2014	31	F	Delivery	Caesarean section	Nothing special	T1-T3	15 h	Mild pain in the left scapular region and back	N/A	Epidural anesthesia (L1−L2)
Madhugiri et al., 2012	23	F	Delivery	Caesarean section	Nothing special	T6-T8	10 h	Paraesthesia over both lower limbs	Hemoglobin = 8 g%; Normal platelet count, bleeding time, clotting time and PT-INR	Spinal anesthesia (L3-L4)
Buchanan et al., 2013	65	F	Surgery	Orthotopic liver transplantation	Hepatitis C-related cirrhosis and hepatocellular carcinoma; Hypertension; Uterine cancer; Abodominal hemetoma and cardiac arrest after OLT	C7-T6	10 days	Plegic in both lower extremities	Nothing special	N/A
SreeHarsha et al., 2006	78	F	Postoperative anti-coagulation	Total knee replacement	Diabetes; Hypertension; Polyarticular rheumatoid arthritis (11 years); Lung carcinoma and pulmonary lobectomy (1 year)	T10-L3	2 days	Severe back pain	Nothing special	Combined spinal and epidural analgesia (L2−L3)
Schwarz et al., 2004	90	F	Thoracic epidural catheter insertion and postoperative anti-coagulation	Subtotal gastrectomy	Gastric adenocarcinoma	T3-T11	2 days	Flaccid lower extremity paralysis and paresthesia without back pain	Nothing special	General anesthesia
Yao et al., 2018	69	F	Intrathecal operation and postoperative anti-coagulation	Stent graft implantation	Hypertension	T11-L3	40 h	Numbness and swelling of lower extremities	A low hemoglobin concentration (64 g/L) and a low platelet count (55 × 109/L)	Spinal anesthesia (L3-L4)
Jaeger et al., 2012	61	F	Surgery and postoperative anti-coagulation	Proximal tibial osteotomy	N/A	C2-T8	2 days	progressive bilateral lower limb weakness and numbness	Nothing special	General anesthesia
Hatim et al., 2005	55	M	Surgery	Total hip replacement	Ankylosing spondylitis; diabetes	T5-T10	2 days	Complete sensory and motor loss in the lower limbs; Urine and bowel dysfunction	N/A	Epidural anesthesia (L3-L4)
Nandra et al., 2019	65	M	Surgery and postoperative anti-coagulation	Coronary angioplasty	Hypertension; Hyper-cholesterolemia	C5-C7	12 h	Right shoulder pain	N/A	N/A
Shoji et al., 2022	84	M	Surgery and postoperative anti-coagulation	Transcatheter aortic valve replacement	Symptomatic severe aortic valve stenosis	T7-T10	5 h	Paraplegia in both legs with vesicorectal disturbances	N/A	N/A
Kin et al., 2014	86	F	Hypertension and hemodialysis therapy	Aortic valve replacement and coronary artery bypass graft	Severe aortic valve stenosis; Hypertension; Chronic renal dysfunction	C2-C6	3 days	Sudden neck pain	Before symptom: PT-INR 2.39, Platelet 55 × 103/ml; After symptom: PT-INR 3.42, Platelet 57 × 103/μL	N/A
Current Study	71	F	Postoperative raised abdominal pressure	Femoral head replacement	Left unilateral femoral neck fracture with concomitant terrible osteoporosis and multi-segmental vertebral compression fracture	T3-L2	1 day	Sensory decline, motor defect	Nothing special	Epidural anesthesia (L3-L4)

F, female; M, male; N/A, not available; INR, international normalized ratio.

4. Discussion

Spontaneous spinal epidural hematoma (SSEDH), defined as a neurological emergency caused by hemorrhage in the epidural space of spinal cord without specific etiological factors [4], is a catastrophic clinical emergency that with incidence of below 0.01 % according to previously published studies [5,6,7]. Although it is rare, patients from infants to the senior all have the chance to suffer from it [8,9,10] and the overdue diagnosis and disposition would bring about serious consequences [11,12,13], which makes it essential to dig deeper about this disease.

Several studies have documented the SSEDH to some possible triggers including pregnancy [14,15,16,17,18], thrombolysis and anticoagulation medicine usage [19,20,21] and vascular malformation [22,23] while the accurate pathophysiology remain mystery. Precedented research summarized the controversy over the etiology of SSEDH that whether the rupture of epidural veins or arteries or cryptic angiomas causes this urgent condition, among which the hypothesis about venous plexus dominates due to their specific anatomical features [1]. In the current case, since this patient hadn't received anti-coagulation therapy, we speculate that the fuse may be the nausea happened the day before SSEDH. Nausea can bring about the raised intra-abdominal pressure, which leads to an unstable hemodynamics within the venous plexus and increase the bleeding risk [2,24]. Moreover, our patient received epidural anesthesia at L3-L4 level during the femoral head replacement surgery, while the SSEDH happened at T3-L2 level. Among all SEDH, incidence rate of cases happening after epidural anesthesia is estimated to be 7 %, which takes a small part [25]. Besides, the level of epidural anesthesia and SSEDH are diverse, reducing the suspicion of epidural anesthesia in this case.

Notably, early precise diagnosis and active surgical intervention of SSEDH play a predominant role for the great outcomes as removal of neurological deficits [26]. Though variable, the typical symptoms of SSEDH include pain, sensory and motor deficit, hinting possible abnormalities of nervous system. However, symptoms won't always be distinctive, which results in the fact that physical examination and auxiliary examinations are needed for accurate diagnosis. MRI is an essential tool in the process of diagnosing SSEDH, which can not only differentiate SSEDH from other diseases such as stroke [27], Guillain-Barre Syndrome (GBS) [12], meningitis [28], but also specifically locate the lesion. Once diagnosed with SSEDH, proper dispositions including surgical decompression and conservative treatment should be taken. The former one is usually applied to more severe patients while the latter is often adapted to cases with minor symptoms. A case-control report found that the cases, who received surgical treatment, were elder, had a higher incidence of thoracic spine involvement and had worse Frankel grade both before and after treatment. Thus, it's hard to lead to the conclusion that prognosis of surgical treatment is worse than that of conservative treatment. The choice of therapeutic schedule and the prognosis both depend on the state of the illness [29]. In this case, the lesion was located at T3-L2 level, the symptoms of this patient were remarkable with worse Frankel grade and this patient could endure surgical treatment, that's why we chose to perform an operation to evacuate the hematoma. Fortunately, the patient recovered well.

Herein, we reviewed the literatures of SSEDH cases and reported one occurred at perioperative of non-spinal surgeries. With these cases, we want to emphasize that clinicians should be vigilant about the delayed postoperative SSEDH though it's non-spinal operation, especially when the patient is old.

5. Conclusion

Clinicians should enhance their knowledge of SSEDH and remain vigilant towards this condition. Literature review highlights the significance of factors such as aging in the development of SSEDH following non-spinal surgeries in the perioperative period.

Ethical approval

This study was approved by the Institutional Review Board (IRB) of Qilu Hospital of Shandong University.

Funding

None.

Registration of research studies

None.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Guarantor

Dr. Lin Cheng and Dr. Cheng Qiu.

CRediT authorship contribution statement

Study concept or design: Tiehan Lin, Manyu Li, Kai Bian; Data analysis or interpretation: Tiehan Lin, Cheng Qiu; Writing the paper: Tiehan Lin, Lin Cheng; Supervision: Lin Cheng.

Declaration of competing interest

The authors declare that they have no conflicts of interest.