Spinal epidural hematoma after spinal manipulation therapy:Report of three cases and a literature review

BACKGROUND Spinal manipulation therapy(SMT)has been widely used worldwide to treat musculoskeletal diseases,but it can cause serious adverse events.Spinal epidural hematoma(SEH)caused by SMT is a rare emergency that can cause neurological dysfunction.We herein report three cases of SEH after SMT.CASE SUMMARY The first case was a 30-year-old woman who experienced neck pain and numbness in both upper limbs immediately after SMT.Her symptoms persisted after 3 d of conservative treatment,and she was admitted to our hospital.Magnetic resonance imaging(MRI)demonstrated an SEH,extending from C6 to C7.The second case was a 55-year-old man with sudden back pain 1 d after SMT,numbness in both lower limbs,an inability to stand or walk,and difficulty urinating.MRI revealed an SEH,extending from T1 to T3.The third case was a 28-year-old man who suddenly developed symptoms of numbness in both lower limbs 4 h after SMT.He was unable to stand or walk and experienced mild back pain.MRI revealed an SEH,extending from T1 to T2.All three patients underwent surgery after failed conservative treatment.The three cases recovered to ASIA grade E on day 5,1 wk,and day 10 after surgery,respectively.All patients returned to normal after 3 mo of follow-up.CONCLUSION SEH caused by SMT is very rare,and the condition of each patient should be evaluated in full detail before operation.SEH should be diagnosed immediately and actively treated by surgery.

Spontaneous Spinal Epidural Hematoma Causing Paraplegia: A Case Report

A spontaneous spinal epidural hematoma without any identified etiology is a very rare entity. We report here a 44 years old woman admitted within our department for 04 days of severe back pain complicated rapidly of bilateral lower-limbs weakness and urinary retention. Neurological examination found a complete paraplegia (0/5 stergh), with incomplete sensory deficit below the T-10 level, bowel and bladder dysfunction, decreased deep and superficial reflex. MRI with different sequences showed a large epidural mass lesion with slightly high signal intensity on T1-weighted images and heterogeneous low signal intensity on T2-weighted images from T11 to L1 suggesting an epidural hematoma. She underwent an urgent total laminectomy from T11 to L1 following by a complete removal of a large dark and compact epidural hematoma compressing the spinal cord. Operatively, there’s no sign suggesting an AVM. Postoperative course was uneventful and she was discharged ten days after surgery with complete recovery.

Early Diagnosis of Spontaneous Spinal Epidural Hematoma with Echo-Planar Gradient-Echo T2*-Weighted MR Imaging

Spontaneous spinal epidural hematoma (SSEH) is a rare idiopathic condition that leads to the acute onset of neurological deficits, which can have catastrophic consequences if not recognized early. It is important to make an early precise diagnosis. Spinal epidural hematoma has been increasingly recognized since the advent of magnetic resonance imaging (MRI). However, T1- and T2-weighted gradient-echo sequences are relatively less sensitive to the magnetic susceptibility effects of hemorrhage. Echo-planar gradient-echo T2*-weighted MR imaging (T2* MRI) is sensitive to these magnetic susceptibility effects and is commonly used for the detection of hemorrhage. We reported that the case of a 76-year-old man who presented with tetra paresis had an early diagnosis of spontaneous spinal epidural hematoma early diagnosed by T2* MRI.

Extensive Spinal Epidural Abscess: Cord Compression with Permanent Neurological Defects

Spinal epidural abscesses (SEA) are considerably rare and tend to present over two to five vertebral segments. Occasionally, there will be two or more noncontiguous areas of pyogenic collections [1]. Minimal cases have been reported to span the entire vertebral column;a meta-analysis estimates that 1% of all SEA are holospinal [2]. The triad of presenting symptoms includes fever, back pain (often midline), and neurologic defects [1] [2] [3]. Early detection is identified as a critical aspect of improved outcomes. Cases that do not present in this manner or with other masking symptoms can lead to delayed diagnosis, thus delaying treatment. In the event of cord compression, the occurrence of neurologic defects increases. Time from the onset of clinical manifestations to the operating room is crucial in reversing symptoms [2]. This article seeks to review a case of a 65-year-old male that presented to the emergency department (ED) due to a falling second to weakness and thigh pain. On presentation, he was also noted to have rhabdomyolysis causing acute kidney injury (AKI) with tubular necrosis. The patient was admitted to the hospital with a complex history of progressive leg weakness, pain in the lower back, incontinence, and elevated white blood cell count. Days into the admission, a magnetic resonance imaging (MRI) study was performed, which revealed a continuous posterior SEA from C4 to S2 with anterior mass effect causing spinal cord compression. Emergency neurosurgery was scheduled for laminectomies in the cervical, thoracic and lumbar spine to drain the abscess. Evaluation of this complex medical course, surgical approach to drainage of an incessant spinal column abscess, and sustained neurologic defects will be discussed.

Acute spontaneous thoracic epidural hematoma associated with intraspinal lymphangioma: A case report

BACKGROUND Spontaneous spinal epidural hematoma is a rare neurosurgical emergency.CASE SUMMARY A 53-year-old healthy woman suffered from complete paraplegia in both legs and loss of all sensation below the xiphoid process.She was diagnosed as acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma.The primary lab survey showed all within normal limits.Presence of a posteriorly epidural space-occupying lesion at the T4-T8 level of the spinal canal was confirmed on magnetic resonance imaging.A decompressive laminectomy was performed from the T4 to T7 levels at the sixth hour following abrupt onset of complete paraplegia.The lesion was confirmed as lymphangioma.This patient recovered well within one month.CONCLUSION This study reports a case of acute spontaneous thoracic epidural hematoma caused by an intraspinal lymphangioma with well recovery after surgical intervention.

Multiple different remote epidural hematomas after craniotomy:A case report

BACKGROUND Epidural hematoma is one of the common postoperative complications after craniotomy.However,multiple remote epidural hematomas in different sites,including supratentorial and infratentorial regions,are exceedingly rare.CASE SUMMARY We present a rare case in which three remote epidural hematomas occurred after craniotomy.A 21-year-old woman was admitted with a headache for 1 mo,vomiting,and rapid vision loss for 1 wk.Brian magnetic resonance imaging indicated a right thalamic tumor.The intraoperative diagnosis was a cystic tumor,posterior cerebral artery aneurysm,and vascular malformation.The operation was successful.Unfortunately,the patient developed three extradural hematomas within 48 h.Family members consented to the first two hematoma evacuations but refused the third.CONCLUSION More attention should be paid to this kind of rare complication.Adequate preoperative evaluation is important,especially for acute patients.Monitoring neural function and early computed tomography scanning of the brain after surgery should be highlighted.

Safety and effectiveness of electromyography-induced rehabilitation treatment after epidural electrical stimulation for spinal cord injury:study protocol for a prospective,randomized,controlled trial

Epidural electrical stimulation is a new treatment method for spinal cord injury(SCI).Its efficacy and safety have previously been reported.Rehabilitation treatment after epidural electrical stimulation is important to ensure and improve the postoperative efficacy of epidural electrical stimulation in patients with SCI.Considering that electromyography(EMG)-induced rehabilitation treatment can accurately match the muscle contraction of patients with SCI,we designed a study protocol for a prospective,randomized controlled trial.In this trial,on the premise of adjusting the spinal cord electrical stimulator to obtain the maximum EMG signal of the target muscle,patients with SCI receiving epidural electrical stimulation will undergo EMG-induced rehabilitation treatment.Recovery of muscle strength of key muscles,quality of life,safety and therapeutic effects will be monitored.Twenty patients with SCI who are scheduled to undergo epidural electrical stimulation in Shanghai Ruijin Rehabilitation Hospital will be randomly divided into two groups with 10 patients per group.The control group will receive conventional rehabilitation treatment.The EMG-induced rehabilitation group will receive EMG-induced rehabilitation treatment of the target muscles of the upper and lower limbs based on conventional rehabilitation treatment.After rehabilitation treatment,follow up for all patients will occur at 2 weeks and 1,3 and 6 months.The primary outcome measure of this trial will be evaluation of target muscle recovery using the Manual Muscle Testing grading scale.Secondary outcome measures will include modified Barthel Index scores,integrated EMG values,the visual analogue scale,Spinal Cord Independence Measure scores,and modified Ashworth scale scores.The safety indicator will be the incidence of adverse events.This trial will collect data regarding the therapeutic effects of EMG-induced rehabilitation in patients with SCI receiving epidural electrical stimulation for 6 months after rehabilitation treatment.Findings from this trial will help develop rehabilitation methods in patients with SCI after epidural electrical stimulation.This study protocol was approved by Ethics Committee of Shanghai Ruijin Rehabilitation Hospital(Approval No.RKIRB2022-12)on February 15,2022 and was registered with Chinese Clinical Trial Registry(registration number:ChiCTR2200061674;date:June 30,2022).Study protocol version:1.0.

Modified surgical method of supra-and infratentorial epidural hematoma and the related anatomical study of the squamous part of the occipital bone

BACKGROUND Supra-and infratentorial acute epidural hematoma(SIEDH)is a common posterior cranial fossa epidural hematoma located at the inner surface of the squamous part of the occipital bone(SOB).Traditionally,surgical treatment of the SIEDH requires a combined supra-infratentorial craniotomy.AIM To analyze the morphological characteristics of the SOB and introduce a single supratentorial craniotomy for SIEDH.METHODS Skull computed tomography(CT)scan data from 32 adult patients were collected from January 1,2019 to January 31,2020.On the median sagittal plane of the CT scan,the angle of the SOB(ASOB)was defined by two lines:Line A was defined from the lambdoid suture(LambS)to the external occipital protuberance(EOP),while line B was defined from the EOP to the posterior edge of the foramen magnum(poFM).The operative angle for the SIEDH(OAS)from the supra-to infratentorial epidural space was determined by two lines:The first line passes from the midpoint between the EOP and the LambS to the poFM,while the second line passes from the EOP to the poFM.The ASOB and OAS were measured and analyzed.RESULTS Based on the anatomical study,a single supratentorial craniotomy was performed in 8 patients with SIEDH.The procedure and the results of the modified surgical method were demonstrated in detail.For males,the ASOB was 118.4±4.7 and the OAS was 15.1±1.8;for females,the ASOB was 130.4±5.1 and the OAS was 12.8±2.0.There were significant differences between males and females both in ASOB and OAS.The smaller the ASOB was,the larger the OAS was.The bone flaps in 8 patients were designed above the transverse sinus intraoperatively,and the SIEDH was completely removed without suboccipital craniotomy.The SOB does not present as a single straight plane but bends at an angle around the EOP and the superior nuchal lines.The OAS was negatively correlated with the ASOB.CONCLUSION The single supratentorial craniotomy for SIEDH is reliable and effective.

Analgesic Effect of Combined Spinal-Epidural Anesthesia and its Effect on TNF-α and CRP Levels in Elderly Patients with Hip Fracture During Surgical Treatment

Objective:To observe the analgesic effect of combined spinal and epidural anesthesia on older patients undergoing hip fracture surgery.Method:One hundred and twenty elderly hip fracture surgery patients treated in our hospital from January 2021 to December 2022 were selected and randomly divided into two groups,with 60 cases in the experimental group and 60 in the control group.The experimental group was given combined spinal-epidural anesthesia intervention measures,while the control group was given epidural anesthesia intervention measures.The analgesic effect,tumor necrosis factor-alpha(TNF-α),C-reactive protein(CRP)levels,and other observation indicators were analyzed after anesthesia intervention.Result:After the intervention,the analgesic effect and the evaluation results of the subjects in the experimental group were better than those in the control group(P<0.05);the obtained values of TNF-αand CRP levels in the experimental group were higher than those of the control group(P<0.05).Conclusion:The combined spinal-epidural anesthesia intervention demonstrated positive outcomes.The analgesic effect of patients during surgery and their inflammatory factor levels improved,which makes this intervention worthy of clinical application and promotion.

Is It Safe to Perform an Autologous Epidural Blood Patch on Patients with Underlying Spinal Stenosis or Lumbar Disc Disease? Case Report and Literature Review

The most common spinal pathology seen in the obstetric population is lumbar disc herniation. There is currently no literature documenting the safety of performing an epidural blood patch on obstetric patients with underlying spinal pathology. We present a case of a patient with known severe lumbar spinal stenosis with compressive radiculopathy who received a successful epidural blood patch without worsening her underlying neurologic symptoms. Epidural blood patches can be safely performed in this patient population. However, the anesthesiologist should be aware of the risk of potentially worsening preexisting neurological deficits. Thus, we advise caution prior to placing an epidural blood patch on these patients. The risks and benefits of the procedure should be carefully weighed and considered. It is important to have a thorough discussion with the patient regarding the risks of an epidural blood patch prior to performing the procedure.

Spontaneous Thoracic Spinal Epidural HematomaDuring Pregnancy

To editor:Spontaneous spinal epidural hematoma(SSEH)is uncom-mon,especially during pregnancy.However,SSEH is a seriousemergency that must be managed immediately to prevent per-manent neurological deficit of the mother and stillbirth.Theetiology and pathogenesis of SEEH remain unknown,al-though multiple theories and precipitating factors are de-scribed in the literature.In this report,we describe the caseof a pregnant female who developed SSEH.

Effects of Combined Spinal Epidural Anaesthesia and Spinal Anaesthesia on Peri-Operative Pulmonary Status in Geriatric Patients in Lower Extremity Surgery

Background: Lower extremity surgeries performed in elderly people usually have high prevalence of peri-operative medical problems related to anaesthesia. The overall objective of peri-operative care of geriatric population is to fast recovery from anaesthesia and avoid functional decline. Objective: To compare the peri-operative pulmonary status of combined spinal epidural anaesthesia (CSEA) and spinal anaesthesia (SA) in geriatric patients underwent lower extremity surgeries. Methods: This prospective comparative study was conducted at Department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2016 to June 2018. A total of 70 geriatric cases that underwent lower extremity surgeries were included in this study. Cases were randomly allocated into two groups;35 in Group A (CSEA) and 35 in Group B (SAB). The different outcome variables between the groups like-duration of anaesthesia, respiratory rates (RR), oxygen saturation (SpO2), end tidal CO2 (EtCO2), peak expiratory flow rate (PEFR), breath holding test (BHT), peri-operative side effects of anaesthesia and post-operative visual analogue score (VAS) were analyzed and compared by statistical tests. Results: The mean age, weight, BMI of Group A and Group B patients were not significantly different (p > 0.05). No significant differences were observed in duration of surgery, gender and ASA grade between the groups (p > 0.05). Mean duration of anaesthesia, mean time to achieve target level of sensory block and mean time to achieve complete motor block were significantly higher in Group A (p < 0.001). Mean RR, SpO2, EtCO2, PEFR and BHT of both groups were not significantly different (p > 0.05). Peri-operative side effects of anaesthesia and post-operative VAS were significantly less in group A patients (p < 0.05). Conclusion: Combined spinal epidural anaesthesia is effective and safe;produces stable peri-operative pulmonary status with prolonging analgesia and fewer side effects as compared to spinal anaesthesia in geriatric patients.

Onyx embolization of a spinal epidural hemorrhage caused by thoracic spinal epidural arteriovenous fistula:A case report and literature review

Spinal epidural hemorrhages(SEDH)caused by spinal epidural arteriovenous fistulas(SEAVFs)are rare;thus,their specific pathogenesis has not been explained.Furthermore,the standard treatment for SEAVFs has not yet been defined.Here we report the case of a 36-year-old Chinese man who experienced acute onset chest pain and tightness.His symptoms rapidly aggravated until the lower limbs were unable to support him.Spinal magnetic resonance angiography(MRA)revealed a localized SEAVF and a secondary spinal cord lesion at the T4 level.Digital subtraction angiography(DSA)confirmed the presence of the SEDH/SEAVF at the T3–4 level with the left radicular artery feeding the fistula.Based on DSA and MRA findings,SEDH,local spinal cord infarction,and spinal venous reflux disorder were conditionally diagnosed.Using the arterial route,Onyx-34 was injected into the fistula to embolize the feeding arteries and the venous system.Angiography was performed after the microcatheter was withdrawn,and no residual fistula or anterior spinal artery was observed.The six-week follow-up MRI showed acceptable healing of the SEAVF,and the patient improved neurologically.This case suggests that endovascular treatment with Onyx-34 embolization should be considered a promising treatment strategy for this type of complicated SEAVF.

Delayed arterial symptomatic epidural hematoma on the 14th day after posterior lumbar interbody fusion:A case report

BACKGROUND Delayed arterial symptomatic epidural hematoma(SEH)on the 14th day after posterior lumbar interbody fusion(PLIF)is rare but it may lead to severe complications if not identified and treated in a timely manner.After diagnosis of the current case,early surgical removal of the hematoma and strict hemostasis treatment was accomplished.This case report highlights the importance of swift diagnosis and treatment in SEH patients.CASE SUMMARY A 41-year-old male patient with a single-segment lumbar disc herniation underwent left-side PLIF.On the 14th post-operative day,the patient complained of lumbar incision pain with sudden onset accompanied by left limb radiation pain and aggravated cauda equina symptoms.Magnetic resonance imaging examination and a puncture blood draw at the incision site confirmed a delayed arterial SEH.Emergency surgical removal of the hematoma and hemostasis was performed.About 70 mL of hematoma was found in the left incision.Continuous bleeding was found in the anterior branch of the transverse process of the 4th lumbar artery in the muscle area about 2 cm below the transverse process of the 4th lumbar vertebra.A blood jet of about 10 cm in height was observed and bipolar electrocoagulation was used to stop the bleeding.Post-operative lumbar incision pain and left lower limb pain were relieved immediately and gradually disappeared.There was no recurrence during the 12-mo follow-up.CONCLUSION For delayed arterial SEH on the 14th day after PLIF,preventive measures including pre-,intra-and post-operative prevention should be implemented.

Spontaneous acute epidural hematoma secondary to skull and dural metastasis of hepatocellular carcinoma: A case report

BACKGROUND The skull and dura are uncommon sites for the metastasis of hepatocellular carcinoma(HCC).Spontaneous acute epidural hematoma(AEDH)is also very rare.We report here a spontaneous AEDH secondary to skull and dural metastasis of HCC.This case is extremely rare.CASE SUMMARY A 48-year-old male patient with a history of HCC developed unconsciousness spontaneously.Head computed tomography showed"a huge AEDH in the left parietal and occipital region with osteolytic destruction of the left parietal bone.Emergent operation was performed to evacuate the hematoma and resect the lesion.Pathological study revealed that the lesion was the metastases from HCC.The patient died of lung infection,anemia,and liver failure 3 wk after operation.CONCLUSION Spontaneous AEDH caused by hepatocellular carcinoma(HCC)dural and skull metastases is extremely rare,the outcome is poor.So,early diagnosis is important.If the level of AFP does not decrease with the shrinkage of intrahepatic lesions after treatment,it is necessary to be alert to the existence of extrahepatic metastases.Since most of the patients had scalp and bone masses,physicians should pay attention to the patient's head palpation.Once a patient with the history of HCC had sudden neurological dysfunction,the possibility of spontaneous AEDH caused by the skull and dura mater metastases should be considered.Since hemorrhage is common in the skull HCC metastases,for patients with spontaneous AEDH accompanied by skull osteolytic lesions,it is also necessary to be alert to the possibility of HCC.For AEDH secondary to HCC metastases,early diagnosis and timely treatment are critical to improve the patients’outcomes.

Spontaneous Cervical Epidural Hematomas in Mild Cervical Spondylotic Myelopathy Patients：An Analysis of 8 Cases

Spontaneous cervical epidural hematoms（SCEH） complicated with mild cervical spondylotic myelopathy（CSM） is a rare but emerging condition.Early diagnosis and treatment are important for good outcomes.This study aimed to investigate the clinical characteristics of this condition and to discuss the optimal treatment.The clinical data from 8 patients with SCEH plus CSM who were divided into two groups by treatment methods were retrospectively analyzed.The neurological function of the patients was assessed by Japanese Orthopedic Association（JOA） score before and after the surgical operations.Other factors were reviewed with medical records.Among them,4 out of the 8 patients underwent emergency surgery,and the rest 3 patients experienced an initial conservative treatment and ultimately received a laminectomy.We found that the Frankel Scale scores in most of the surgical patients were increased after surgery（6/7,85.7%）.However,the JOA scores at the 6th month after onset were even lower than those before onset in 3 of the operative cases,and those in the patients who were given conservative treatment showed no significant change.It was concluded that some patients with SCEH and CSM treated with a timely operation may obtain relief from their previous CSM symptoms.However,the final neurological deficits of these patients were closely related to the progressive interval which refers to the hours between the initial onset and the occurrence of new neurological deficits or mild CSM deterioration,no matter whether they accept the operation.We found the crucial progressive interval may be in 9 h.Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits.

Pneumocephalus Following Combined Spinal-Epidural Anesthesia: A Case Report Analysis

Background: Combined spinal-epidural anesthesia (CSEA) is widely used in clinical anesthesia due to its rapid onset, reliable anesthetic effect, and strong controllability. Although advancements in technique have reduced the frequency and severity of common complications, reports of rare and serious complications such as pneumocephalus, remain scarce. Case Report: This article presents a case of pneumocephalus following CSEA in a middle-aged female patient undergoing surgery for an intrauterine space-occupying lesion. The patient experienced severe headache postoperatively, and imaging confirmed the presence of intracranial air. After receiving active symptomatic treatment, the patient recovered and was discharged. Conclusion: This case underscores the importance of adhering to standard anesthesia protocols and increasing awareness of rare CSEA complications, particularly the risk of pneumocephalus. Early recognition and timely management are crucial. There is a need to further enhance training and research in anesthetic procedures to improve clinical anesthesia quality and ensure patient safety.

Retrospective study on progressive epidural hematoma

Objective To study the clinical issues of progressive epidural hematoma ( PEDH ) Methods The incidence,impacts on clinical course and short term outcomes and predictors of PEDH were retrospectively studied. Results PEDH occurred in 20. 3% of the patients. The rates of neurological deterioration and

Resolution of epidural hematoma related to osteoporotic fracture after percutaneous vertebroplasty

We are the first to report a case that showed spontaneous resolution of epidural hematoma which was related to a steroid-induced osteoporotic compression fracture.The patient had a painful fracture with an intravertebral cleft at L1 accompanying an epidural hematoma posteriorly.Immediate pain relief was achieved after percutaneous vertebroplasty.Complete resolution of hematoma was noted three months after procedure.We theorized that intravertebral stability after treatment might have played a role in this patient.

Acute Epidural Hematoma Compressing the Dominant Sigmoid Sinus as an Unusual Cause of Intracranial Hypertension: Case Report and Review of Literature

Post traumatic dural sinus vein stenosis has been rarely described in pediatric population. We present a case of a 9-year-old child that had sustained a head injury after a fall from height causing an acute epidural hematoma compressing the dominant sigmoid sinus. The patient had developed sub acutely signs and symptoms of increased intracranial pressure. Prophylactic treatment with anticoagulants was initiated despite the presence of an intracranial bleeding. Clinical and radiological improvements were achieved. We had also reviewed the literature regarding this uncommon entity and discussed other existing diagnostic and therapeutic alternatives. Further gathering of information is essential in order to form a therapeutic protocol.