Article

PDF
Access to the PDF text
Service d'aide à la décision clinique
Advertising


Free Article !

Neurochirurgie
Volume 59, n° 2
pages 105-107 (avril 2013)
Doi : 10.1016/j.neuchi.2012.10.140
Received : 3 June 2012 ;  accepted : 16 October 2012
Recurrent spinal epidural hematoma: Case report
Hématome épidural récidivant du rachis : à propos d’un cas
 

R. Caruso a, b, , A. Pesce a, V. Wierzbicki a, L. Marrocco a
a Neurosurgical division, army medical center of Rome, Piazza Celimontana 50, 00184 Rome, Italy 
b Department of neurology and psychiatry, university of Rome “La Sapienza”, Viale dell’Università 30, Rome, Italy 

Corresponding author.
Abstract

We report the case of a man of 65 who, at 20 and 37days from surgery of C6 corpectomy, experienced two epidural hematomas at C7-D1. We assume that the pathogenic cause of this rare disease was an overlap between three main factors: the surgical aggression of the internal anterior epidural venous plexus; a possible increase of intra-thoracic pressure due to chronic obstructive pulmonary disease; and double antiplatelet drug therapy.

The full text of this article is available in PDF format.
Résumé

Nous rapportons le cas d’un homme de 65ans qui, à 20 et 37jours d’une corporectomie C6, a présenté deux hématomes épiduraux au niveau de C7-D1. Nous supposons que la cause pathogène de cette affection rare résulte de la conjonction de trois principaux facteurs : agression chirurgicale du plexus veineux épidural antérieur interne, possible augmentation de la pression intrathoracique en raison de la maladie pulmonaire obstructive chronique associée, et, double thérapie antiplaquettaire.

The full text of this article is available in PDF format.

Keywords : Epidural, Hematoma, Myelopathy, Spinal, Recurrence

Mots clés : Hématome épidural, Myélopathie, Rachis, Récurrence


Spontaneous spinal epidural hematoma is a rare clinical entity; recurrence after reabsorption or evacuation is even a rarer event [1, 3, 2]. For this reason, we think it is interesting to report our clinical case.

Case report

In 2009, a 65years old man with a history of chronic obstructive pulmonary disease and acute heart attack and under dual antiplatelet therapy (aspirin and clopidogrel), came for the first time to our centre complaining intense neck pain, progressive walking difficulty and weakness of the upper arms, with major difficulty in feeding himself. The examination showed marked tetra-hyperreflexia, motor deficit involving the left upper arm, and frank hyposthenia on both legs. The MRI findings showed a cervical spondylotic myelopathy at C5-C6 level. He was treated surgically with anterior cervical discectomy with fusion. Tetra-hyperreflexia unchanged, but the patient’s mobility and sensory ability improved significantly. At the time of the first surgery, the drugs could not be withdrawn for surgical purpose but no hemorrhagic phenomena took place.

In October 2011, the patient showed a dramatic clinical worsening. The patient referred a recent and abrupt worsening of the neck pain, with increasing walking and feeding difficulties. At the neurological examination, he was found to have tetra-hyposthenia with tetra-hyperreflexia. The MRI showed the presence of an adjacent space pathology involving the C6-C7 level, below the one previously treated, plus massive hyperostosis and calcification of the posterior longitudinal ligament. Few days later, the patient underwent an anterior C6 corpectomy, with cage-in-peek replacement of the soma. Postoperative course was uncomplicated and regular without notes of any clinical relevance. The first control, 15days later, showed a significant improvement of both pain and neurological symptomatology. The patient had continued taking dual antiplatelet therapy as usual.

Twenty days after the surgery the patient was admitted at the emergency department of our hospital with an acute flaccid tetra-paresis (motor deficit: Royal Medical Council 4/5), tetra-hyperreflexia and once again fairly strong neck pain. The MRI showed the presence of a huge anterior epidural hematoma compressing the spine at C7-D1 level, below the levels previously treated. We immediately performed a posterior C7-D1 decompressive laminectomy. The postoperative course was regular. Five days after surgery an MRI showed only a very small remnant of the original epidural hematoma, and a spinal cord free from any compressive element and completely surrounded by LCS (Fig. 1). The 7th and 14th day-controls showed a significant clinical improvement and a notable regression of the tetra-paretic symptomatology.



Fig. 1


Fig. 1. 

The T2 weighted MRI shows: A. A huge epidural hematoma involving the level below the ones previously treated. B. A very small remnant of the original epidural hematoma, and a spinal cord free from any compressive element 5days after surgery.

L’IRM pondérée en T2 montre : A. Un hématome épidural impliquant le niveau au-dessous de celui déjà traité. B. Un résidu de l’hématome épidural originel, et une moelle épinière libre de tout élément de compression, cinq jours après la chirurgie.

Zoom

On day 17 after the decompressive laminectomy, the patient came back to the emergency department with the same acute tetra-paretic symptomatology. The MRI showed a recurrent epidural hematoma at the same level. The patient was treated conservatively; antiplatelet drugs treatment was definitively suspended. An in-depth study of the coagulation parameters was performed. Prothrombin time (PT), partial thromboplastin time (PTT), thrombin time (TT), bleeding time (BT) and tromboelastography provided no evidence of haemorrhagic diathesis as well as the dosing of the VIII, IX, and XIII factors. Platelets were within the normal range from both the quantitative and the qualitative point of views (No, platelet distribution width [PDW]). Fibrinogen, fibrine degradation produces (FDP) and D-Dimer witnessed, instead, for a functional coagulative process. The MRI, before the patient’s discharge, showed only a little remnant of the second epidural hematoma recurrence: our conservative strategy was successful (Fig. 2). The patient was discharged from our department in good medical condition and showing progressive improvement of the neurologic symptomatology. He was sent to a neurological rehabilitation department. At the time of writing, in the lapse of five months, no relapse was recorded and neurological conditions appear on further improvement.



Fig. 2


Fig. 2. 

The T2-weighted MRI scan shows: A. The relapse of the epidural hematoma. B. A little remnant of the second epidural hematoma recurrence 12days later.

L’IRM pondérée en T2 montre : A. La réapparition de l’hématome épidural. B. Douze jours plus tard, un résidu de la récidive du deuxième hématome épidural.

Zoom

Discussion

The causes of both epidural hematomas remain unclear. We have rejected the possibility of an epidural angioma because all the MRIs performed before and after the surgeries haven’t showed any suspicious vascular malformation. Haematological examination provided no sufficient evidence of coagulopathy or other pathologies of the aggregation process related to the antiplatelet treatment. Given our patient’s general condition, we assumed an overlap between three main pathogenetic factors:

the surgical aggression of the internal anterior epidural venous plexus at the level of the first surgery;
a possible increase of intra-thoracic pressure due to the chronic obstructive pulmonary disease, chronically transmitted to the internal epidural venous plexus;
double antiplatelet drug that causes a bleeding risk increase.

To our knowledge, there are only few reported cases of spontaneous recurrent spinal epidural hematoma in literature. This case can be considered as something between a spontaneous form and a traumatic form. In fact, the time of hematoma formation is inconsistent with a perioperative bleeding as well as the same location is fully inconsistent with a form related to the presence of hemorrhagic diathesis. It is clear that any new, progressive neurological symptom in antiplatelet drug treated patients should never be undervalued. Clopidogrel and aspirin or other anticoagulant therapeutic options, like warfarin, have shown a powerful hemorrhagic potential in high risk cardiovascular patients [4].

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

References

Abram H.S., Delahunt M.J., Merinbaum D.J., Hammond D.N. Recurrent spontaneous spinal epidural hematoma in a child: first case report Pediatr. Neurol. 2007 ;  36 : 177-180 [inter-ref]
Zhong W., Chen H., You C., Li J., Liu Y., Huang S. Spontaneous spinal epidural hematoma J. Clin. Neurosci. 2011 ;  18 : 1490-1494 [cross-ref]
Sano H., Satomi K., JH. Recurrent idiopathic epidural hematoma: a case report J. Orthop. Sci. 2004 ; 625-628 [cross-ref]
Lim S.H., Hong B.Y., Cho Y.R., Kim H.S., Lee J.I., Kim H.W., and al. Relapsed spontaneous spinal epidural hematoma associated with aspirin and clopidogrel Neurol. Sci. 2011 ;  32 : 687-689 [cross-ref]



© 2012  Elsevier Masson SAS. All Rights Reserved.
EM-CONSULTE.COM is registrered at the CNIL, déclaration n° 1286925.
As per the Law relating to information storage and personal integrity, you have the right to oppose (art 26 of that law), access (art 34 of that law) and rectify (art 36 of that law) your personal data. You may thus request that your data, should it be inaccurate, incomplete, unclear, outdated, not be used or stored, be corrected, clarified, updated or deleted.
Personal information regarding our website's visitors, including their identity, is confidential.
The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
Close
Article Outline
You can move this window by clicking on the headline