Case Presentation
A 58-year-old Malay woman with a history of well-controlled hypertension, hyperlipidemia, type II diabetes mellitus, and microscopic hematuria underwent a cystoscopy to investigate the hematuria, revealing no abnormalities. There was no history of recent infection, trauma, coagulopathy, or surgery. She arrived at our emergency department with an abrupt onset of back pain, accompanied by weakness and numbness in both lower limbs that swiftly progressed over a few hours. Initial blood investigations, including a full blood count, electrolyte panel, international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT), returned within normal limits. Subsequent imaging identified a spinal epidural hematoma, prompting immediate decompressive surgery from thoracic (T) 9 to lumbar (L) 1. The patient then underwent postoperative rehabilitation for paralysis.
Examination
Upon examination, the patient displayed flaccid paraplegia with a sensory level of T12. Doctors noticed diminished deep tendon reflexes and the absence of the Babinski sign bilaterally in the lower limbs. There were no signs of upper-limb weakness or cranial nerve involvement. Laboratory tests, encompassing a complete blood count and coagulation profile, indicated normal results. Additionally, the patient exhibited hypertensive urgency, with a systolic blood pressure of 188 mmHg, which was subsequently alleviated by anti-hypertensive administration.
The initial magnetic resonance imaging (MRI) of the entire spine uncovered a spinal epidural hematoma extending from the T9 to L1 levels. This resulted in substantial spinal cord compression.
The patient underwent a thorough evaluation by the medical team in the emergency department. In a prompt response, doctors conducted the MRI images and analyzed them within an hour.
Management: Spinal Hematoma
Due to the patient’s deterioration in neurological status, an immediate surgical intervention was prompted. The patient received an initial dose of intravenous dexamethasone (8 mg), followed by 4 mg every 8 hours. Moreover, within three hours of completing the MRI and a laminectomy of the T9 to L1 vertebrae. The doctors performed spinal cord compression to alleviate. They also evacuated the hematoma.
During the surgery, a considerable epidural hematoma was identified and effectively removed. Baseline assessments revealed robust somatosensory evoked potentials (SSEP) in the bilateral upper limbs. However, weakness was noted in the bilateral lower limbs, without any intraoperative changes. While the baseline motor evoked potential (MEP) in the upper limb exhibited satisfactory results. There was no response in the bilateral lower limbs. This remained unchanged during the surgery. Baseline electromyography (EMG) in the bilateral lower limbs demonstrated intermittent irritation.
Post-operative
Postoperatively, the patient was started on rehabilitation in a step-down facility. However, despite these interventions, her motor and sensory functions remained absent.
Discussions were held with both the patient and the department of radiology regarding a computed tomography (CT) whole spine angiogram to rule out an arteriovenous malformation. Nevertheless, the patient chose to forego this investigative procedure due to the combination of low diagnostic yield and high radiation exposure.
A subsequent MRI of the entire spine showed the resolution of the hematoma at the affected levels. This indicated a positive outcome following the surgical intervention.
Spinal Hematoma
Spontaneous spinal epidural hematomas are exceptionally rare and typically linked to vascular anomalies or coagulation disorders. The exact origins of SSEH remain poorly understood but are theorized to result from arteriovenous malformations, the rupture of epidural vessels, or epidural veins. This case highlights the critical importance of swift diagnosis and timely surgical intervention in instances of acute and severe spinal cord compression. Symptoms can vary widely, encompassing motor weakness, sensory deficits, bowel and bladder dysfunction, neck pain, back pain, leg pain, abdominal discomfort, and gait instability. Differential diagnoses should include considerations for conditions like epidural abscess, spinal cord ischemia, and transverse myelitis.
Utilizing magnetic resonance imaging (MRI) as the gold standard for diagnosis allows for precise visualization of the hematoma and its impact on the spinal cord. A comprehensive literature review highlights that early surgical decompression, particularly in patients with incomplete neurological deficits or the absence of sensory deficits, correlates with superior neurological outcomes.
It is crucial to highlight the necessity of maintaining mean arterial pressure (MAP) above 80 mmHg. Adequate perfusion pressure is paramount to preventing secondary spinal cord injury.
