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Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy
The Spine Journal 3 (2003) 539–542
Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy Michael P. Steinmetz, MDa, Iain H. Kalfas, MDa,*, Byron Willis, MDb, Ali Chalavi, MDa, Richard C. Harlan, MDc a
Department of Neurosurgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA b Neurological Surgeons, PC, 345 E. Virginin Avenue, Phoenix, AZ 85004, USA c Department of Obstetrics and Gynecology, Ohio Permanente Group, 12301 Snow Road, Parma, OH 44130, USA Received 19 February 2003; accepted 4 August 2003
Abstract
BACKGROUND CONTEXT: A spontaneous epidural hematoma of the spine occurring during pregnancy is extremely rare. The development of a significant neurologic deficit may be rapid. Therefore, the neurosurgeon should be aware of the presentation, diagnosis and treatment options available. PURPOSE: The authors report a case of a spontaneous epidural hematoma of the spine during the third trimester of pregnancy, which was successfully managed with surgical evacuation. The case is unique in that the patient demonstrated a subacute presentation. STUDY DESIGN: The authors report a case of a 27-year-old primagravada presented with the subacute onset of progressive paraparesis. She became nonambulatory before admission. A magnetic resonance imaging study (MRI) demonstrated ventral epidural compression in the upper thoracic region. METHODS: A retrospective review of a case of spontaneous epidural hematoma of the spine during pregnancy was performed. The inpatient and outpatient charts were used to gather clinical information of the case, and the pertinent radiographs and images were reviewed. RESULTS: An urgent cesarean section was performed followed by evacuation of the epidural hematoma. The decompression was performed by means of a thoracic laminectomy with partial facetectomy. The patient had a prompt return of neurologic function. CONCLUSION: Spontaneous epidural hematoma of the spine should be suspected in the setting of acute back or neck pain with or without an associated progressive neurologic deficit. Spine surgeons and obstetricians should also recognize that a spinal epidural hematoma during pregnancy may also present subacutely, as illustrated in our case. Prompt diagnosis may be made with MRI, and evacuation of the hematoma should be performed, ideally before the onset of neurologic signs or symptoms. The prognosis for return of neurologic function is good after urgent evacuation. 쑖 2003 Elsevier Inc. All rights reserved.
Keywords:
Epidural hematoma; Pregnancy; Spine; Spontaneous; Obstetrics
Introduction Spontaneous epidural hematomas of the spine are uncommon. They have been reported to occur iatrogenically after
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this research. * Corresponding author. Section of Spinal Surgery, Department of Neurosurgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel.: (216) 444-9064; fax: (216) 445-6801. E-mail address: [email protected] (I.H. Kalfas) 1529-9430/03/$ – see front matter doi:10.1016/j.spinee.2003.08.026
쑖 2003 Elsevier Inc. All rights reserved.
spinal surgery, during anticoagulant therapy and in association with prolonged valsalva, hemophilia, vasculitis and spinal arteriovenous malformations [1–3]. A spontaneous spinal epidural hematoma occurring during pregnancy is even more rare. To our knowledge, only three cases have been reported in the literature [4–6]. Symptom onset is acute with rapid and progressive neurologic deficit. The case described herein demonstrates that the presentation may also be subacute in nature. Prompt recognition of the symptoms (even before the onset of neurologic deficits) will allow diagnosis and rapid surgical evacuation of the hematoma.
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M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
Case report The patient, a 27year-old woman in the third trimester of her first pregnancy, was admitted at 38 weeks gestation with progressive paraparesis. One week before her admission she noted the sudden onset of severe interscapular pain not associated with any physical activity. The pain persisted but gradually decreased in intensity. Thirty-six hours before admission she developed progressive weakness in both legs along with parasthesias in her legs and torso extending from the nipple line downward. Her neurologic deficit progressed in a subacute fashion until she became nonambulatory approximately 12 hours before admission. Her pregnancy had been uncomplicated, and she was taking only prenatal vitamins before admission. Her past medical history was unremarkable. On admission, the patient’s neurological examination was remarkable for grade 2/5 weakness in both legs proximally and grade 4/5 weakness in both legs distally. Her sensation to light touch and pinprick was diminished in both lower extremities, but proprioception was intact. She had a sensory level at approximately the T4 level. Her lower-extremity deep tendon reflexes were abnormally brisk and her extensor plantar reflexes were present bilaterally. Her rectal tone was normal, but perineal sensation was decreased. Laboratory studies, including platelet count, prothrombin time and protime, were all within normal limits. A magnetic resonance imaging (MRI) study of the thoracic spine revealed a moderate-sized ventral epidural mass at the T1– T2 levels. The signal characteristics of the mass suggested epidural hematoma (Figs. 1 and 2). An obstetrical consultation was obtained, and the gestational age of 38 weeks was confirmed. A decision was made to first proceed with a cesarean section under general anesthesia followed by a thoracic laminectomy for removal of the epidural hematoma. The cesarean section was uneventful, and a healthy male infant was delivered. The patient was then turned into the prone position and a laminectomy was performed at the T1–T2 level. Because of the ventral location of the hematoma, a partial facetectomy was performed on the right side to allow for a posterolateral access to the ventral epidural space. A subacute hematoma was identified, gently manipulated with a nerve hook and removed. No overt bleeding source was identified within the spinal canal. Histolopathologic examination of the surgical specimen revealed only an organized hematoma. Specifically there was no evidence for a vascular malformation. Postoperatively, the patient rapidly regained both motor and sensory function. On the day of discharge (postoperative day 3), her proximal lower extremity strength was 4⫹/5 and her distal strength was 5/5. The patient was ambulatory with minimal assistance. Discussion Spontaneous epidural hematomas of the spine are rare. The etiology is generally unknown [7]. Predisposing factors
Fig. 1. Sagittal T1-weighted magnetic resonance image of the thoracic spine. An epidural hematoma is located ventral to the spinal cord at the T1–T2 level. There is significant compression of the spinal cord.
include anticoagulant therapy, vascular malformations, hemophilia and arteritis [3]. Clinical manifestations typically include the acute onset of neck or back pain followed by radicular symptoms or myelopathy depending on the spinal level of involvement as well as the degree of neural compression. The development of a significant neurological deficit is typically rapid [8]. The illustrative case is unique in that the patient presented in a subacute fashion. Once a neurologic deficit begins, it usually progresses rapidly to paralysis or severe paraparesis. Carroll et al. [5] and Yonekawa et al. [6] each reported a case of epidural hematoma of the spine during pregnancy. Their patients developed profound weakness suddenly and within 3 hours, respectively. The case presented herein demonstrates that the presentation may also be subacute and more gradual. Clinicians caring for pregnant women must be diligent in their workup of acute onset spine or even mild sensory changes. As our case illustrates, these may precede the onset of neurologic signs and symptoms by days. This affords the rapid diagnosis and
M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
Fig. 2. Sagittal T2-weighted magnetic resonance image of the thoracic spine. The epidural hematoma is visualized dorsal to the T1–T2 vertebral bodies.
surgical evacuation of the hematoma before the development of a neurologic deficit. The origin of most spontaneous epidural hematomas is believed to be venous [7,9–11]. Because epidural veins have no valves [12,13], sudden intravenous pressure changes, such as those that can occur with coughing or straining, can be directly transmitted to the epidural venous complex with the potential for rupture. During the late stages of pregnancy, as the uterus and fetus enlarge, the abdominal/pelvic venous dynamics are altered. This fluctuation in venous pressures has been reported to potentially lead to a rupture of a preexisting pathologic venous wall [6]. Because laboratory and pathology studies failed to reveal pathology (ie, vascular malformation), it was believed to be a truly spontaneous epidural hematoma and venous in origin. Obtaining an MRI study is critical in forming the diagnosis of spinal epidural hematoma. Multiplanar MRI can be
541
used to visualize the relationship between the spine and spinal cord, as well as to assess the extent of the hematoma and degree of spinal cord compression [14,15]. MRI provides the surgeon with the necessary anatomic information to create an appropriate management plan for this condition. Surgical decompression is the treatment of choice for most spinal epidural hematomas and should be performed urgently in the setting of a significant or progressive neurological deficit. Our case illustrates that spinal epidural hematomas seen during pregnancy can be evacuated through a laminectomy approach. Their soft, friable consistency permits a relatively easy removal even when they are located in the ventral epidural space. The posterior approach obviates the need for a posterolateral or anterolateral corridor (ie, costotransversectomy or thoracotomy). The authors believe that this permits a more rapid evacuation of the hematoma, which may be extremely important if operating on a pregnant woman or immediately after a cesarean section. When the epidural hematoma occurs in the setting of pregnancy, the surgical management plan will be directed by the gestational age of the fetus. Although surgical decompression of a spinal epidural hematoma can be performed during pregnancy, the advantages of doing so need to be measured against the potential for anesthetic complications that may affect the fetus [4,16]. If the patient is in the first or second trimester, delivery of the fetus would not be feasible. Urgent obstetric consultation is required for fetal monitoring. Spinal epidural anesthesia may more appropriate in this situation compared with general anesthesia [16]. Surgical decompression of the spinal cord should proceed, but careful decisions on patient positioning should be made. An anterolateral or posterolateral approach may be used with the patient in the lateral position (author’s preference). This avoids direct compression of the fetus and also the mother’s aorta and vena cava. During the third trimester of pregnancy, general anesthesia can be administered without undue risk to the fetus. The primary concern with general anesthesia in this setting is the potential for immediate postdelivery neonatal depression. This depression may be limited by the anesthesiologist using higher concentrations of oxygen and only 50% nitrous oxide, combined with low-dose halogenated agents, and a reasonably expeditious delivery time (less than 10 to 15 minutes from induction to delivery) [16]. The prognosis for neurological outcome after surgical decompression of spinal epidural hematomas is directly related to the interval between the onset of symptoms and the surgical decompression. The degree of neurological deficit before decompression is also critical. Foo and Rossier [7] noted that in a series of patients with epidural hematoma and complete sensorimotor loss before surgery, the potential for complete sensorimotor recovery was only 11.3% [7]. Neurological recovery is also directly related to the rate of development and the size of the hematoma [17]. Despite the rapid progression seen in the cases described by Carroll et al. [5] and Yonakawa et al. [6], the presentation may also
542
M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
be subacute, as illustrated by our case. This affords the clinician the ability to diagnose and evacuate the hematoma, possibly before the onset of neurologic signs and symptoms.
Conclusion Spontaneous epidural hematoma of the spine during pregnancy is rare. The diagnosis should be suspected in the setting of acute and significant back or neck pain with an associated progressive neurological deficit. A subacute presentation may also be seen. Obstetricians and spine surgeons should recognize both the acute and subacute nature of spinal epidural hematomas, which may be seen during pregnancy. Diagnosis and decompression should be performed before complete sensorimotor loss ensues, or ideally before neurologic signs and symptoms appear. Management of this condition during pregnancy should be coordinated with an obstetrician. If the gestational age of the fetus permits cesarean section, delivery of the fetus should be performed immediately before the spinal decompression. If a premature gestational age does not permit an early delivery, spinal decompression should be performed urgently, preferably with an epidural anesthetic, although general anesthesia can be tolerated by the fetus in the third trimester.
References [1] Connolly SE, Winfree CJ, McCormick PC. Management of spinal epidural hematoma after tissue plasminogen activator: a case report. Spine 1996;21:1694–7. [2] David S, Salluzo RF, Bartfield JM. Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing. Am J Emerg Med 1997;15:73–5.
[3] Sanchis JR, Orozco M, Cabanes J. Spontaneous extradural hematomas. J Neurol 1975;38:577–80. [4] Bidzinski J. Spontaneous spinal epidural hematoma during pregnancy. J Neurosurg 1966;24:1017. [5] Carroll SG, Malhotra R, Eustace D, Sharr M, Morcus S. Spontaneous spinal extradural hematoma during pregnancy. J Mat Fetal Med 1997;6:218–9. [6] Yonekawa Y, Mehdorn HM, Nishikawa M. Spontaneous spinal epidural hematoma during pregnancy. Surg Neurol 1975;3:327–8. [7] Foo D, Rossier AB. Preoperative neurological status is predicting surgical outcome of spinal epidural hematomas. Surg Neurol 1981; 15:389–401. [8] Saito S, Katsube H, Kobayashi Y. Spinal epidural hematoma with spontaneous recovery demonstrated by magnetic resonance imaging. Spine 1994;19:483–6. [9] Brawn LA, Bergval UEG, Davies-Jones GAB. Spontaneous spinal epidural hematoma with spontaneous resolution. Postgrad Med J 1986;62:885–7. [10] Hernandez D, Vinuela R, Feasby TE. Recurrent paraplegia with total recovery from spontaneous spinal epidural hematoma. Ann Neurol 1982;11:623–4. [11] Rothfus WE, Chedid MK, Deeb ZL, Abla AA, Maroon JC, Sherman RL. MR imaging in the diagnosis of spontaneous spinal epidural hematoma. J Comput Assist Tomogr 1987;11:851–4. [12] Kaplan LI, Denker P. Acute non-traumatic spinal epidural hematoma. Am J Surg 1949;78:356–61. [13] Nogore M. Clinical anatomy of the vertebral veins. Surgery 1945; 17:606–15. [14] Lagmayr JJ, Ortler M, Dessl A, Twerdy K, Aichner F, Felber S. Management of spontaneous extramedullary spinal hematomas: results in eight patients after MRI diagnosis and surgical decompression. J Neurol Neurosurg Psychiatry 1995;59:442–7. [15] LaRosa G, D’Avella D, Conti A, et al. Magnetic resonance imagingmonitored conservative management of traumatic spinal epidural hematomas. J Neurosurg (Spine 1) 1999;91:128–32. [16] Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G, editors. Anesthesia for obstetrics. Baltimore: Williams and Wilkins, 1993:236–8. [17] Cooper DW. Spontaneous spinal epidural hematoma. J Neurosurg 1967;26:343–6.
Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy Michael P. Steinmetz, MDa, Iain H. Kalfas, MDa,*, Byron Willis, MDb, Ali Chalavi, MDa, Richard C. Harlan, MDc a
Department of Neurosurgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA b Neurological Surgeons, PC, 345 E. Virginin Avenue, Phoenix, AZ 85004, USA c Department of Obstetrics and Gynecology, Ohio Permanente Group, 12301 Snow Road, Parma, OH 44130, USA Received 19 February 2003; accepted 4 August 2003
Abstract
BACKGROUND CONTEXT: A spontaneous epidural hematoma of the spine occurring during pregnancy is extremely rare. The development of a significant neurologic deficit may be rapid. Therefore, the neurosurgeon should be aware of the presentation, diagnosis and treatment options available. PURPOSE: The authors report a case of a spontaneous epidural hematoma of the spine during the third trimester of pregnancy, which was successfully managed with surgical evacuation. The case is unique in that the patient demonstrated a subacute presentation. STUDY DESIGN: The authors report a case of a 27-year-old primagravada presented with the subacute onset of progressive paraparesis. She became nonambulatory before admission. A magnetic resonance imaging study (MRI) demonstrated ventral epidural compression in the upper thoracic region. METHODS: A retrospective review of a case of spontaneous epidural hematoma of the spine during pregnancy was performed. The inpatient and outpatient charts were used to gather clinical information of the case, and the pertinent radiographs and images were reviewed. RESULTS: An urgent cesarean section was performed followed by evacuation of the epidural hematoma. The decompression was performed by means of a thoracic laminectomy with partial facetectomy. The patient had a prompt return of neurologic function. CONCLUSION: Spontaneous epidural hematoma of the spine should be suspected in the setting of acute back or neck pain with or without an associated progressive neurologic deficit. Spine surgeons and obstetricians should also recognize that a spinal epidural hematoma during pregnancy may also present subacutely, as illustrated in our case. Prompt diagnosis may be made with MRI, and evacuation of the hematoma should be performed, ideally before the onset of neurologic signs or symptoms. The prognosis for return of neurologic function is good after urgent evacuation. 쑖 2003 Elsevier Inc. All rights reserved.
Keywords:
Epidural hematoma; Pregnancy; Spine; Spontaneous; Obstetrics
Introduction Spontaneous epidural hematomas of the spine are uncommon. They have been reported to occur iatrogenically after
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this research. * Corresponding author. Section of Spinal Surgery, Department of Neurosurgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Tel.: (216) 444-9064; fax: (216) 445-6801. E-mail address: [email protected] (I.H. Kalfas) 1529-9430/03/$ – see front matter doi:10.1016/j.spinee.2003.08.026
쑖 2003 Elsevier Inc. All rights reserved.
spinal surgery, during anticoagulant therapy and in association with prolonged valsalva, hemophilia, vasculitis and spinal arteriovenous malformations [1–3]. A spontaneous spinal epidural hematoma occurring during pregnancy is even more rare. To our knowledge, only three cases have been reported in the literature [4–6]. Symptom onset is acute with rapid and progressive neurologic deficit. The case described herein demonstrates that the presentation may also be subacute in nature. Prompt recognition of the symptoms (even before the onset of neurologic deficits) will allow diagnosis and rapid surgical evacuation of the hematoma.
540
M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
Case report The patient, a 27year-old woman in the third trimester of her first pregnancy, was admitted at 38 weeks gestation with progressive paraparesis. One week before her admission she noted the sudden onset of severe interscapular pain not associated with any physical activity. The pain persisted but gradually decreased in intensity. Thirty-six hours before admission she developed progressive weakness in both legs along with parasthesias in her legs and torso extending from the nipple line downward. Her neurologic deficit progressed in a subacute fashion until she became nonambulatory approximately 12 hours before admission. Her pregnancy had been uncomplicated, and she was taking only prenatal vitamins before admission. Her past medical history was unremarkable. On admission, the patient’s neurological examination was remarkable for grade 2/5 weakness in both legs proximally and grade 4/5 weakness in both legs distally. Her sensation to light touch and pinprick was diminished in both lower extremities, but proprioception was intact. She had a sensory level at approximately the T4 level. Her lower-extremity deep tendon reflexes were abnormally brisk and her extensor plantar reflexes were present bilaterally. Her rectal tone was normal, but perineal sensation was decreased. Laboratory studies, including platelet count, prothrombin time and protime, were all within normal limits. A magnetic resonance imaging (MRI) study of the thoracic spine revealed a moderate-sized ventral epidural mass at the T1– T2 levels. The signal characteristics of the mass suggested epidural hematoma (Figs. 1 and 2). An obstetrical consultation was obtained, and the gestational age of 38 weeks was confirmed. A decision was made to first proceed with a cesarean section under general anesthesia followed by a thoracic laminectomy for removal of the epidural hematoma. The cesarean section was uneventful, and a healthy male infant was delivered. The patient was then turned into the prone position and a laminectomy was performed at the T1–T2 level. Because of the ventral location of the hematoma, a partial facetectomy was performed on the right side to allow for a posterolateral access to the ventral epidural space. A subacute hematoma was identified, gently manipulated with a nerve hook and removed. No overt bleeding source was identified within the spinal canal. Histolopathologic examination of the surgical specimen revealed only an organized hematoma. Specifically there was no evidence for a vascular malformation. Postoperatively, the patient rapidly regained both motor and sensory function. On the day of discharge (postoperative day 3), her proximal lower extremity strength was 4⫹/5 and her distal strength was 5/5. The patient was ambulatory with minimal assistance. Discussion Spontaneous epidural hematomas of the spine are rare. The etiology is generally unknown [7]. Predisposing factors
Fig. 1. Sagittal T1-weighted magnetic resonance image of the thoracic spine. An epidural hematoma is located ventral to the spinal cord at the T1–T2 level. There is significant compression of the spinal cord.
include anticoagulant therapy, vascular malformations, hemophilia and arteritis [3]. Clinical manifestations typically include the acute onset of neck or back pain followed by radicular symptoms or myelopathy depending on the spinal level of involvement as well as the degree of neural compression. The development of a significant neurological deficit is typically rapid [8]. The illustrative case is unique in that the patient presented in a subacute fashion. Once a neurologic deficit begins, it usually progresses rapidly to paralysis or severe paraparesis. Carroll et al. [5] and Yonekawa et al. [6] each reported a case of epidural hematoma of the spine during pregnancy. Their patients developed profound weakness suddenly and within 3 hours, respectively. The case presented herein demonstrates that the presentation may also be subacute and more gradual. Clinicians caring for pregnant women must be diligent in their workup of acute onset spine or even mild sensory changes. As our case illustrates, these may precede the onset of neurologic signs and symptoms by days. This affords the rapid diagnosis and
M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
Fig. 2. Sagittal T2-weighted magnetic resonance image of the thoracic spine. The epidural hematoma is visualized dorsal to the T1–T2 vertebral bodies.
surgical evacuation of the hematoma before the development of a neurologic deficit. The origin of most spontaneous epidural hematomas is believed to be venous [7,9–11]. Because epidural veins have no valves [12,13], sudden intravenous pressure changes, such as those that can occur with coughing or straining, can be directly transmitted to the epidural venous complex with the potential for rupture. During the late stages of pregnancy, as the uterus and fetus enlarge, the abdominal/pelvic venous dynamics are altered. This fluctuation in venous pressures has been reported to potentially lead to a rupture of a preexisting pathologic venous wall [6]. Because laboratory and pathology studies failed to reveal pathology (ie, vascular malformation), it was believed to be a truly spontaneous epidural hematoma and venous in origin. Obtaining an MRI study is critical in forming the diagnosis of spinal epidural hematoma. Multiplanar MRI can be
541
used to visualize the relationship between the spine and spinal cord, as well as to assess the extent of the hematoma and degree of spinal cord compression [14,15]. MRI provides the surgeon with the necessary anatomic information to create an appropriate management plan for this condition. Surgical decompression is the treatment of choice for most spinal epidural hematomas and should be performed urgently in the setting of a significant or progressive neurological deficit. Our case illustrates that spinal epidural hematomas seen during pregnancy can be evacuated through a laminectomy approach. Their soft, friable consistency permits a relatively easy removal even when they are located in the ventral epidural space. The posterior approach obviates the need for a posterolateral or anterolateral corridor (ie, costotransversectomy or thoracotomy). The authors believe that this permits a more rapid evacuation of the hematoma, which may be extremely important if operating on a pregnant woman or immediately after a cesarean section. When the epidural hematoma occurs in the setting of pregnancy, the surgical management plan will be directed by the gestational age of the fetus. Although surgical decompression of a spinal epidural hematoma can be performed during pregnancy, the advantages of doing so need to be measured against the potential for anesthetic complications that may affect the fetus [4,16]. If the patient is in the first or second trimester, delivery of the fetus would not be feasible. Urgent obstetric consultation is required for fetal monitoring. Spinal epidural anesthesia may more appropriate in this situation compared with general anesthesia [16]. Surgical decompression of the spinal cord should proceed, but careful decisions on patient positioning should be made. An anterolateral or posterolateral approach may be used with the patient in the lateral position (author’s preference). This avoids direct compression of the fetus and also the mother’s aorta and vena cava. During the third trimester of pregnancy, general anesthesia can be administered without undue risk to the fetus. The primary concern with general anesthesia in this setting is the potential for immediate postdelivery neonatal depression. This depression may be limited by the anesthesiologist using higher concentrations of oxygen and only 50% nitrous oxide, combined with low-dose halogenated agents, and a reasonably expeditious delivery time (less than 10 to 15 minutes from induction to delivery) [16]. The prognosis for neurological outcome after surgical decompression of spinal epidural hematomas is directly related to the interval between the onset of symptoms and the surgical decompression. The degree of neurological deficit before decompression is also critical. Foo and Rossier [7] noted that in a series of patients with epidural hematoma and complete sensorimotor loss before surgery, the potential for complete sensorimotor recovery was only 11.3% [7]. Neurological recovery is also directly related to the rate of development and the size of the hematoma [17]. Despite the rapid progression seen in the cases described by Carroll et al. [5] and Yonakawa et al. [6], the presentation may also
542
M.P. Steinmetz et al. / The Spine Journal 3 (2003) 539–542
be subacute, as illustrated by our case. This affords the clinician the ability to diagnose and evacuate the hematoma, possibly before the onset of neurologic signs and symptoms.
Conclusion Spontaneous epidural hematoma of the spine during pregnancy is rare. The diagnosis should be suspected in the setting of acute and significant back or neck pain with an associated progressive neurological deficit. A subacute presentation may also be seen. Obstetricians and spine surgeons should recognize both the acute and subacute nature of spinal epidural hematomas, which may be seen during pregnancy. Diagnosis and decompression should be performed before complete sensorimotor loss ensues, or ideally before neurologic signs and symptoms appear. Management of this condition during pregnancy should be coordinated with an obstetrician. If the gestational age of the fetus permits cesarean section, delivery of the fetus should be performed immediately before the spinal decompression. If a premature gestational age does not permit an early delivery, spinal decompression should be performed urgently, preferably with an epidural anesthetic, although general anesthesia can be tolerated by the fetus in the third trimester.
References [1] Connolly SE, Winfree CJ, McCormick PC. Management of spinal epidural hematoma after tissue plasminogen activator: a case report. Spine 1996;21:1694–7. [2] David S, Salluzo RF, Bartfield JM. Spontaneous cervicothoracic epidural hematoma following prolonged valsalva secondary to trumpet playing. Am J Emerg Med 1997;15:73–5.
[3] Sanchis JR, Orozco M, Cabanes J. Spontaneous extradural hematomas. J Neurol 1975;38:577–80. [4] Bidzinski J. Spontaneous spinal epidural hematoma during pregnancy. J Neurosurg 1966;24:1017. [5] Carroll SG, Malhotra R, Eustace D, Sharr M, Morcus S. Spontaneous spinal extradural hematoma during pregnancy. J Mat Fetal Med 1997;6:218–9. [6] Yonekawa Y, Mehdorn HM, Nishikawa M. Spontaneous spinal epidural hematoma during pregnancy. Surg Neurol 1975;3:327–8. [7] Foo D, Rossier AB. Preoperative neurological status is predicting surgical outcome of spinal epidural hematomas. Surg Neurol 1981; 15:389–401. [8] Saito S, Katsube H, Kobayashi Y. Spinal epidural hematoma with spontaneous recovery demonstrated by magnetic resonance imaging. Spine 1994;19:483–6. [9] Brawn LA, Bergval UEG, Davies-Jones GAB. Spontaneous spinal epidural hematoma with spontaneous resolution. Postgrad Med J 1986;62:885–7. [10] Hernandez D, Vinuela R, Feasby TE. Recurrent paraplegia with total recovery from spontaneous spinal epidural hematoma. Ann Neurol 1982;11:623–4. [11] Rothfus WE, Chedid MK, Deeb ZL, Abla AA, Maroon JC, Sherman RL. MR imaging in the diagnosis of spontaneous spinal epidural hematoma. J Comput Assist Tomogr 1987;11:851–4. [12] Kaplan LI, Denker P. Acute non-traumatic spinal epidural hematoma. Am J Surg 1949;78:356–61. [13] Nogore M. Clinical anatomy of the vertebral veins. Surgery 1945; 17:606–15. [14] Lagmayr JJ, Ortler M, Dessl A, Twerdy K, Aichner F, Felber S. Management of spontaneous extramedullary spinal hematomas: results in eight patients after MRI diagnosis and surgical decompression. J Neurol Neurosurg Psychiatry 1995;59:442–7. [15] LaRosa G, D’Avella D, Conti A, et al. Magnetic resonance imagingmonitored conservative management of traumatic spinal epidural hematomas. J Neurosurg (Spine 1) 1999;91:128–32. [16] Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G, editors. Anesthesia for obstetrics. Baltimore: Williams and Wilkins, 1993:236–8. [17] Cooper DW. Spontaneous spinal epidural hematoma. J Neurosurg 1967;26:343–6.