Spontaneous resolution of traumatic cervical epidural hematoma: illustrative case

Abstract

BACKGROUND

Cervical epidural hematomas are rare and can arise for many reasons. Patients typically present with pain and/or symptoms of spinal cord compression. Prompt surgical decompression is typically pursued when deficits are present in an effort to improve long-term neurological outcomes. However, the authors report the case of a patient with a traumatic dorsal cervical epidural hematoma with spontaneous resolution within 16 hours.

OBSERVATIONS

A 49-year-old male with a history of C5–6 anterior cervical fusion 3 years prior presented with neck pain after blunt force trauma. The exam revealed only tenderness in the cervical spine. Initial computed tomography revealed fractures of C1 and C4. Urgent magnetic resonance imaging (MRI) demonstrated a dorsal cervical epidural hematoma causing compression of the spinal cord from the occiput to C5. An operation was scheduled for the following morning; however, after he reported new symptoms, repeat MRI was performed, which confirmed no evidence of a cervical epidural hematoma.

LESSONS

This case demonstrates that a traumatic cervical epidural hematoma can resolve spontaneously within a short time frame. Close monitoring of these patients is vital, and it is important to reimage patients if new signs and/or symptoms arise to potentially change the timing and/or nature of the proposed surgery.

https://thejns.org/doi/10.3171/CASE24167

A spinal hematoma is an accumulation of blood that can compress the spinal cord and nerve roots. Epidural spinal hematomas are uncommon, accounting for less than 1% of all spinal canal space-occupying lesions.^1–3 Anticoagulant therapy tends to be the most common risk factor for developing clinically significant spinal hematomas.^{4, 5} Other causes include vascular malformations, vasculopathies, and tumoral hemorrhages.^{5, 6} Cervical epidural hematomas caused by trauma are an even rarer occurrence compared to those arising spontaneously. Traumatic spinal epidural hematomas often require urgent decompression if they cause neurological impairment. We present a case of a posterior traumatic cervical epidural hematoma that spontaneously resolved within 16 hours.

Illustrative Case

A 49-year-old male presented with neck pain in the emergency department after being struck by a tree branch while operating machinery. The patient did not take anticoagulants. His prior history was significant for an anterior C5–6 spinal surgery 3 years prior with no complications. During the neurological examination, the patient reported tenderness in his shoulders and midline neck pain, without focal motor or sensory deficit. Initial computed tomography (CT) and magnetic resonance imaging (MRI) revealed C1 anterior and posterior arch fractures, C1 lateral mass fracture, and C4 burst fracture. There was also ligamentous injury to the interspinous ligaments at C1–2 and C5–6 and the ligamentum flavum at C4. Prevertebral soft tissue edema within the upper cervical spine was also noted. Additionally, a circumferential epidural hematoma was causing moderate to severe thecal sac and spinal cord compression from the occiput to C5 in the cervical spine (Fig. 1). The T1-weighted MRI distinguished the posterior hematoma from cerebrospinal fluid (Fig. 2). The patient was scheduled for surgery the following morning; however, 16 hours later, the patient reported new pain, weakness, and numbness bilaterally down his arms. Due to this new neurological decline, repeat MRI was performed, showing no evidence of the cervical epidural hematoma (Fig. 3). A posterior decompression was no longer necessary since the hematoma had disappeared. The patient underwent a C5 corpectomy for biomechanical stabilization, and the C1 fracture was maintained in a cervical collar for 10 weeks. There was no older blood noted at the time of surgery. The patient was discharged with no postoperative complications.

FIG. 1.

Initial sagittal T2-weighted MRI demonstrating a dorsal epidural hematoma from the occiput to C5.

FIG. 2.

Initial sagittal T1-weighted MRI demonstrating posterior cervical epidural hematoma distinguished from cerebrospinal fluid.

FIG. 3.

Repeat sagittal T2-weighted MRI demonstrating resolution of the previously noted cervical epidural hematoma 16 hours later.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

There are differing opinions in the literature on whether the etiology of traumatic spinal epidural hematomas is arterial or venous.⁷ One theory suggests that stretching and increased traction on the epidural arterial cascade can lead to hemorrhage.^{8, 9} Others have proposed that the venous plexus in the epidural space is vulnerable to rupture with sudden changes, leading to hemorrhage.^{9, 10} Sharp edges from fractured bone can lead to injury of adjacent vasculature, edges from a traumatic durotomy can lead to bleeding, and fractured cancellous bone can cause slow oozing as well. In this case, it appears that hemorrhage in the dorsal paraspinal musculature tracked into the spinal canal.

Cervical epidural hematomas commonly arise spontaneously and are less commonly secondary to trauma. The reported incidence of posttraumatic cervical epidural hematomas from 2010 to 2014 was 2.5%, and of these, 59% were related to spinal cord compression.¹¹ Almost all documented cases of traumatic cervical epidural hematomas in the literature required surgical intervention.^{7, 12} A few cases of traumatic epidural hematoma in other regions of the spine (anterior cervical and lumbar spine) were reported to have spontaneously resolved: 1 case in the anterior cervical epidural space and 4 cases in the lumbar epidural space. Lefranc et al. described a 27-year-old male with a traumatic hematoma from C2 to C6 that resolved after 4 hours in the presence of a C7 fracture.⁹ In the lumbar epidural region, La Rosa et al. reported 4 cases of traumatic hematoma in the presence of vertebral fractures that had spontaneously resolved in 8–10 days.¹³ Some risk factors for traumatic epidural hematomas were associated with a higher severity of injury, an elevated international normalized ratio, and patients with ankylosing spondylitis.¹¹

Presentation

The classic clinical presentation of a spinal epidural hematoma is an acute onset of severe back or neck pain that may or may not be associated with symptoms of nerve root and/or spinal cord compression.² Likewise, traumatic cervical epidural hematomas typically present with pain, numbness, and/or paresis. Similarly, the present case involved pain, weakness, and numbness. Kashyap et al. discussed 5 cases of traumatic cervical epidural hematoma causing Brown-Sequard syndrome.⁷ Similar exam findings should warrant advanced spinal imaging to further investigate the cause of patients’ symptoms.

Diagnosis and Treatment

The gold-standard imaging modality for the diagnosis and evaluation of epidural spinal hematomas is MRI without contrast. In rare situations in which MRI cannot be promptly performed, such as due to implanted MR-incompatible devices, an urgent CT myelogram can be considered to pinpoint areas of spinal compression. Spinal hematomas require early surgical intervention if they are causing neurological deficits to maximize the likelihood of improved neurological outcomes. It is important, however, to determine the cause of the neurological deficit when present. Detailed neurological assessment coupled with an in-depth review of imaging is necessary to ascertain if the injury is related to bony compression, ligamentous instability, spinal cord infarction, central cord syndrome, compression by the hematoma, spinal shock, or a combination of causes. In the case presented, bony compression was thought to represent the primary cause of the spinal cord injury; therefore, spinal stabilization with cervical corpectomy was chosen as the planned intervention. Surgical decompression and evacuation of the hematoma is the mainstay treatment to resolve neurological symptoms when the spinal hematoma is the primary cause of injury.¹⁴ In some cases, despite urgent intervention, the patient’s deficits do not improve, and long-term rehabilitation may be indicated.¹⁴

Lessons

This case report demonstrates the possibility of a traumatic cervical epidural hematoma spontaneously resolving. The hematoma resolving without surgical decompression is the best outcome. In the present case, the patient underwent surgery to repair cervical spine fractures and recovered postoperatively. Urgent evaluation via MRI should be employed when there is suspicion of a spinal epidural hematoma. It is difficult to predict when spontaneous recovery of the epidural hematoma will occur after trauma; however, it is vitally important to understand the cause of spinal injury and to move forward with timely and appropriate treatment.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Graffeo, Spence. Acquisition of data: Fassina, Spence. Analysis and interpretation of data: Fassina, Spence. Drafting the article: Fassina, Spence. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Graffeo. Statistical analysis: Fassina. Administrative/technical/material support: Graffeo. Study supervision: Graffeo.

Correspondence

Christopher S. Graffeo: University of Oklahoma Health Sciences Center, Oklahoma City, OK. graffeo@gmail.com.