Spontaneous idiopathic cervical spinal epidural hematoma mimicking tumor: A case report

Abstract

Background:

Spontaneous spinal epidural hematomas (SSEHs) are a rare. Cervical SSEHs, though less common than thoracic or lumbar variants, pose a heightened risk of morbidity due to proximity to the brainstem and spinal cord making timely diagnosis treatment even more critical.

Case Description:

A 50-year-old female presented with chronic neck pain for 1 week presented with the rapid onset of a progressive quadriparesis. The cervical magnetic resonance imaging revealed a posterior SSEH extending from C4 to T2, with maximal cord compression at C6–C7; the radiological differential diagnosis favored epidural hematoma versus tumor. She underwent an urgent decompressive laminectomy for evacuation of hematoma; pathology revealed no neoplasia or vascular malformation. Postoperatively, she recovered marked neurological motor function.

Conclusion:

Cervical SSEHs are rare and require immediate magnetic resonance diagnosis and surgical decompression to optimize neurological recovery.

INTRODUCTION

Spontaneous spinal epidural hematomas (SSEHs) are rare, particularly in the absence of trauma or known underlying coagulopathies or vascular malformations; they occur in 0.1/100,000 individuals a year.[1,8] While most occur in the thoracic spine, cervical SSEHs (i.e., frequency of 15–20%) carry a disproportionately higher risk of morbidity.[4] As SSEHs are relatively rare, other more frequent differential considerations include tumor, infarct, or transverse myelitis.[6] Prompt diagnosis through magnetic resonance imaging (MRI) and timely surgical decompression are essential to optimize outcomes. Herein, a 50-year-old female developed a progressive quadriparesis over 1 week due to a cervical SSEH; following resection, the patient sustained significant neurological motor recovery.

CASE PRESENTATION

A 50-year-old female presented with 3 weeks of neck pain and a rapidly progressive quadriparesis. Neurologically, she had motor weakness in the right upper (3/5) and left upper limbs (4/5), with preserved lower limb motor function. The sensory examination revealed diminished sensation in both upper extremities alone. She had hyperreflexia and bilaterally positive Hoffman’s signs. The cervical myelogram [Figure 1] and MRI [Figure 2] revealed a large posterior spinal epidural collection extending from C4 to T2, with maximal compression at the C6–C7 level; there was severe canal narrowing and a faint T2 hyperintensity at C5 consistent. The lesion exhibited mixed signal intensity on T1 and T2-weighted imaging and included internal septations and areas of dark T2 signal suggestive of hemosiderin deposition. It did not enhance with contrast. These findings were consistent with an epidural hematoma, although tumor was also considered [Table 1]. The patient underwent an urgent right-sided C5–T1 hemilaminectomy. Intraoperatively, a dark hemorrhagic mass was encountered and completely evacuated. The pathology revealed a clot alone, i.e., no tumor and no vascular malformation [Table 1]. Postoperatively, the patient remained hemodynamically stable and exhibited a good recovery with improvement in upper extremity motor function to (4/5) bilaterally along with retained normal lower extremity motor and sensory functions.

Figure 1:

Preoperative myelogram demonstrating a hyperintense, crescent-shaped lesion visible along the dorsal aspect of the cervical spinal canal, extending from the upper cervical levels downward. The spinal cord appears compressed anteriorly. Findings are consistent with a spontaneous idiopathic cervical epidural hematoma, without evidence of trauma or underlying vascular malformation.

Figure 2:

Preoperative sagittal and axial MRI images of the cervical spine showing a posterior epidural collection from C4 to T2 with cord compression at C6–C7. (a) Sagittal T2-weighted image demonstrating a well-defined hyperintense epidural collection located dorsally (white arrow), extending from approximately C4 to T1, causing anterior displacement and compression of the cervical spinal cord. (b) Axial T2-weighted image at the level of C6–C7 showing the epidural hematoma in the posterior aspect of the spinal canal (white arrow) with effacement of the dorsal cerebrospinal fluid (CSF) space and indentation of the spinal cord. (c) Sagittal T1-weighted image showing the same lesion as isointense to mildly hyperintense relative to the spinal cord (white arrow), consistent with subacute blood products. (d) Axial T1-weighted image again confirming the presence of the posterior epidural mass with spinal cord compression (white arrow), without evidence of vertebral fracture or enhancement.

Table 1:

Case findings and summary.

Hematology evaluation

Postoperative laboratories including complete blood count, coagulation profile, and renal and liver function tests were all within normal limits, and the von Willebrand disease panel and factor XIII assay were within normal range [Table 1].

DISCUSSION

SSEH is an uncommon but potentially devastating condition. Its rarity and variable clinical presentation often result in misdiagnosis or delayed treatment. The cervical spine is involved in fewer than 15% of SSEH cases but is associated with a greater risk of morbidity due to the limited space for cord expansion and the vital functions of the cervical cord.[1,3]

The exact pathogenesis of SSEH remains incompletely understood, and multiple hypotheses have been proposed. The most widely accepted mechanism implicates rupture of the epidural venous plexus (Batson’s plexus), a valveless network of veins directly communicates with the intrathoracic and intra-abdominal venous systems. Sudden increases in intrathoracic or intra-abdominal pressure may transiently elevate venous pressure, leading to vessel rupture and subsequent hematoma formation.[2,7]

However, this venous hypothesis has limitations, particularly in the cervical spine, where epidural venous pressure is generally lower than intrathecal pressure, making venous rupture less plausible. Consequently, some authors have proposed that arterial sources may account for hemorrhage in cervical SSEH. Small arteries in the epidural space are exposed to systemic pressures, and rupture of these fragile vessels could better explain the rapid onset and greater severity of neurological deficits often seen in cervical cases.[5,10] Known risk factors include anticoagulation therapy, vascular malformations, and coagulopathies; however, approximately 40–50% of cases remain idiopathic.[9]

Our patient presented with progressive cervical myelopathy over 1 week, culminating in upper limb weakness, sensory deficits, and gait instability. Notably, she was medically free, had no trauma history or coagulopathy, and her imaging mimicked a neoplastic lesion – highlighting the diagnostic complexity of SSEH. In such cases, MRI remains the gold standard for diagnosis, with T1- and T2-weighted sequences revealing mixed-signal collections and spinal cord compression.[2]

A prompt surgical approach is the most widely accepted treatment for patients with progressive neurological deficits. Several studies emphasize the timing of intervention as a key determinant of outcome. The review of the literature showed that decompression within 12 h significantly improved neurological outcomes compared to delayed surgery.[10] Foo and Rossier reported that the initial neurological status is a strong predictor of prognosis.[4] Our patient underwent surgery within 24 h of admission, resulting in preserved lower limb function and partial upper limb recovery.

Groen and Ponssen reviewed 199 cases and highlighted the role of idiopathic causes in SSEH, recommending urgent surgical evacuation as the mainstay of treatment when neurological impairment is evident.[6]

This case adds to the growing recognition that SSEH can present without a clear etiology and may radiologically mimic neoplastic or infectious processes. Our experience underscores the importance of maintaining SSEH in the differential diagnosis when evaluating spinal epidural lesions, even in the absence of typical risk factors.

CONCLUSION

Cervical SSEHs are rare and should be considered among the differential diagnostic considerations when patients acutely present with the onset of quadriparesis, and early MRI with prompt decompression is critical for preserving function and improving outcomes.

Ethical approval:

Institutional review board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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