自发性椎管内硬膜外血肿的早期识别与临床评估

Spontaneous spinal epidural hematoma： early recognition and clinical evaluation

目的探讨自发性椎管内硬膜外血肿（spontaneous spinal epidural hematoma，SSEH）的早期识别、临床评估及预后的影响因素。方法本组9例SSEH患者，其中男性7例，女性2例，年龄18～83岁，平均45岁。病因：高血压3例，血管瘤2例，椎板成骨细胞瘤2例，神经母细胞瘤1例，溶栓治疗后1例。9例患者中，6例首发症状为颈、肩背部或腰部疼痛；2例以双下肢不全性瘫痪为首发症状。1例溶栓后，出现双下肢上升性感觉、运动障碍。Frankel A级4例，B级2例，C级1例，D级2例。8例行手术治疗，1例溶栓后的患者丧失了最佳手术时机，采用保守治疗。结果MRI提示血肿位于颈胸段1例，胸段8例；累及2～8个节段，平均3．7个节段。除1例患者术后50d死亡外，其他患者均获随访，平均随访时间7．5个月。手术患者末次随访时Frankel B级2例，D级1例，E级4例；1例患者因并发严重的肺部感染，术后50d死亡。1例保守治疗的患者，神经功能无改善。结论SSEH的早期识别主要根据临床特征及MRI提示的损害部位、范围。高血压引起的SSEH预后较差，而肿瘤引起的SSEH在早期诊断、及早手术治疗后疗效尚可。

Objective To investigate early recognition and clinical evaluation of spontaneous spinal epidural hematoma （SSEH） and to analyze the factors related to prognosis. Methods Nine patients with SSEH were include in current study. There were 7 men and 2 women with a mean age of 45.4 years （ range, 18-83 years）. Etiological factors were noted in 9 patients, 3 with hypertension, 2 with angioma, 2 with laminar osteoblastoma, 1 with neuroblastoma, and 1 with thrombolysis treatment. Six patients presented with acute onset of neck or back pain. Two patients initially presented with incomplete paralysis. One patient emerged with ascending bilateral lower extremity weakness and loss of sensation after thrombolysis treatment. Neurologic deficit was four as Frankel A, two as Frankel B, one as Frankel C and two as Frankel D. Evacuation of the hematoma was carried out in eight patients. One patient of thrombolysis treatment was treated conservatively because of loss of optimum for operation. Results Eight hematomas were located in thoracic region, one was found in the cervicothoracic region. Mean extension was 3.7 segments （ range, 2-8 segments）. One patient died of severe pulmonary infection 50 days postoperatively. The average follow-up observation was 7. 5 months. Evaluation of the neurological function showed that 2 patients being classified as Frankel B, 1 as Frankel D and 4 patients as Frankel E. There was no improvement of neurological function in 1 patient with conservative treatment. Conclusions The keys to the early diagnosis of SSEH are the characteristic of clinical symptoms, and the lesion site, the extent of the lesion demonstrated by MRI. The prognosis is worse for SSEH with etiological factor of hypertension. Early diagnosis and surgical treatment might get better results for SSEH resulting from tumour.