Spinal Epidural Hematoma

Aka: Spinal Epidural Hematoma, Traumatic Spinal Epidural Hematoma

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II. Epidemiology

  1. Incidence: <1 per 100,000 hospital admissions
  2. May occur at any age

III. Pathophysiology

  1. Expanding Spinal Epidural Hematoma results in Acute Spinal Cord Compression
    1. Occurs in the epidural space between the dura and the Vertebral wall lining
    2. Most commonly occurs in the thoracolumbar region
  2. Uncommon disorder with potentially devastating results
    1. No risk factor identified in up to 60% of patients
    2. Often occurs without preceding Trauma
    3. Diagnosis missed on initial presentation as often as 90% of cases

IV. Risk Factors

  1. Spinal Injury
  2. Lumbar Puncture
  3. Spinal surgery instrumentation
  4. Bleeding Disorder
  5. Anticoagulation
  6. Arteriovenous Malformation

V. Findings

  1. See Acute Spinal Cord Compression
  2. Back Pain (<25% of patients)
  3. Radiculopathy in a Dermatomal Distribution
  4. Neurologic deficits at or below the Epidural Hematoma (typically rapid, within 3 hours)
    1. Motor deficits (may progress to irreversible paralysis within 1-2 days)
    2. Sensory deficits or Paresthesias
    3. Cauda Equina Syndrome (bowel or Bladder dysfunction, saddle Anesthesia, Foot Drop)

VI. Labs

  1. Consider acute phase reactant markers (C-RP, ESR)
    1. Indicated if Spinal Infection is in differential
  2. Complete Blood Count (CBC)
    1. Evaluate for Thrombocytopenia, Anemia
    2. Evaluate for Leukocytosis in Spinal Infections
  3. Precautions
    1. Avoid Lumbar Puncture (may worsen spread of Hematoma)

VII. Imaging

  1. See Acute Spinal Cord Compression
  2. Gadolinium-enhanced Spine MRI (preferred)
    1. Test Sensitivity >90% for Spinal Epidural Hematoma
    2. Hematoma appears as an enhancing Lesion on T2-Weighted Images (hypointense on T1)
  3. CT Spine with Myelography
    1. Consider when MRI is contraindicated or unavailable
      1. However myelography risks worsening Hematoma, and is relatively contraindicated
      2. Consult neurosurgery regarding imaging with CT myelography versus CT with IV contrast
  4. CT Spine with IV Contrast
    1. May be preferred when MRI is contraindicated due to the risks associated with Myelography
    2. Findings include soft tissue and Vertebral changes and disc narrowing

VIII. Differential Diagnosis

  1. See Spinal Cord Syndrome
  2. See Spinal Infection
  3. Spinal Epidural Abscess

IX. Management

  1. See Acute Spinal Cord Compression
  2. Emergent neurosurgery Consultation for surgical evacuation of Hematoma (e.g. Laminectomy)
    1. Neurologic deficits may lead to permanent paralysis with delays >36 hours
  3. Reversal of Bleeding Diathesis
    1. Reverse Anticoagulation
    2. Consider Platelet Transfusion for severe Thrombocytopenia

X. Prognosis

  1. Mortality: Up to 50%
  2. Neurologic outcome may not be clear for the first year
  3. Poor Prognostic Indicators
    1. Delayed surgical intervention (when indicated)
    2. Long symptom duration
    3. Paralysis at the time of presentation
    4. Rapidly expanding Hematoma
    5. Extensive spine involvement (esp. Thoracic Spine)

XI. References

  1. Dasburg (2020) Crit Dec Emerg Med 34(6): 28-9
  2. Uke and Bronckman (2024) Crit Dec Emerg Med 38(5): 4-8

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