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Spontaneous spinal epidural haematoma (SSEDH) is an uncommon condition presenting with local and radicular pain associated with clinical features of rapidly progressive spinal cord compression. The cause of the bleeding is varied, with anticoagulant therapy recognised to be the commonest known aetiological factor.1 Surgery is the preferred treatment, regardless of aetiology, especially in patients with extensive haematomas and neurological deficits.1 2 Spontaneous resolution of the haematoma is reported but rare.3-5 We report a case of an extensive spontaneous spinal epidural haematoma extending from the upper cervical to lower thoracic region secondary to anticoagulant therapy, with remarkable clinical and radiological improvement with conservative management.
An 82 year old woman was admitted with a one week history of neck pain and upper thoracic pain, which had worsened during the preceding 4 days. On the day before admission, she developed sudden onset of complete paraplegia with urinary retention. She had noticed some improvement in power in her legs and back pain on the day of referral to our institution. She has a medical history of ischaemic heart disease with congestive cardiac failure and was on long term warfarin therapy for atrial fibrillation. At the referring hospital, her intemational normalised ratio (INR) was 10 and she was transferred to our neurosurgical unit after vitamin K and fresh frozen plasma were administered.
When assessed on arrival, she was complaining of mild thoracic pain. There was no neurological abnormality in the upper limbs. Tone was increased in the lower limbs with grade 2 (MRC) power on the left and grade 3 on the right. She had sensory loss to pin prick below D 10 with saddle anaesthesia. Posterior column sensation was preserved. Deep tendon reflexes were pathologically brisk in the lower limbs and planter responses were extensor bilaterally.
Her INR was 1.9 and radiography of the cervical spine showed spondylotic changes and thoracic spine radiography showed evidence of osteoporosis. There was no fracture. Brain MRI showed an intermediate to high signal intensity epidural lesion suggestive of haematoma from C-1 extending to the lower thoracic region, compressing the dorsal aspect of the cord (figure).
As the power in her lower limbs was improving, we elected to treat her conservatively. Her clotting derangement was corrected with vitamin K and fresh frozen plasma while monitoring her INR. Her power continued to improve and at the time of her discharge she had grade 4 power in her legs with associated mild distal sensory loss. Eight weeks later, she had grade 5 power but was slightly unsteady on her feet due to spasticity. Sensory testing was normal. Repeat MRI showed almost complete resolution of the haematoma.
Spontanous spinal epidural haematoma (SSEDH) is an uncommon disorder first described by Jackson in 1869. It usually affects patients in the age group 20 to 70 and the thoracic spine is the commonest region affected. Spinal MRI is the investigation of choice in establishing diagnosis, characteristically showing increased signal intensity in T1 weighted images in an epidural mass at the first examination or increasing signal intensity with time; and in T2 weighted images, showing focal low signal intensity in early stages.4 The aetiology includes vascular malformations, coagulopathies, anticoagulant therapy, aspirin intake, minor trauma and hypertension.1 2 6 In about 40% of cases, the cause is unknown despite extensive investigations.1 About 300 cases of SSEDH have been reported in the world literature.1-6Anticoagulant therapy is the commonest known cause of SSEDH,1 but prothrombin time or INR values do not seem to correlate with the risk of haemorrhage.1 6
Surgery is generally the treatment of choice as the rapid decompression of the spinal cord ensures maximal neurological recovery. It is generally held that early (<12 hours) surgery and good preoperative neurological status promise the best possible outcome, although delayed surgery after total loss of spinal cord function does not completely exclude the possibility of some recovery.1-3
We report a case of SSEDH in an 82 year old lady who was on anticoagulant therapy (warfarin), for cardiovascular disease, and presented with features of spinal cord compression associated with back pain. Spinal MRI disclosed spinal epidural haematoma extending from C-1 to the lower thoracic region. Such an extensive haematoma is very uncommon.1 4 Literature review suggests that SSEDH involving more than two vertebral levels carries a worse prognosis.1 2 Hence, the rapid recovery seen in our patient despite such an extensive haematoma is remarkable.
Improving clinical condition, extensive haematoma, age, and poor medical condition of the patient prompted us to pursue conservative treatment with good clinical and radiological improvement. Although emergency surgery is the treatment of choice, non-surgical therapy in the medically unfit, patients with minor deficits, and in patients with initial clinical improvement, has yielded good results, in all the aetiological groups,1 3 4 which fits with our experience. Fresh frozen plasma, Vitamin K, and monitoring of INR have been the mainstay of conservative treatment in patients on anticoagulants, who need repeat MRI for follow up.3 4With the ever increasing number of patients on anticoagulant therapy for cardiovascular diseases, SSEDH is likely to become a more common problem. When to restart anticoagulant therapy and the optimal INR values to be maintained after restarting are the questions still unanswered in the literature.
In summary, SSEDH in patients taking anticoagulant drugs with initial clinical improvement may be successfully treated with regular clinical, haematological, and MRI monitoring even if they have extensive clots.
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