Spinal Surgery Original Article 8 Analysis of Cervical Spinal Epidural Hematoma in 8 Patients Kotaro Ogihara, M. D., Susumu Sasada,
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1 Spinal Surgery00001 Original Article 8 Analysis of Cervical Spinal Epidural Hematoma in 8 Patients Kotaro Ogihara, M.D., Susumu Sasada, M.D., Tokuhisa Shindo, M.D., Shinji Otsuka, M.D., Noboru Kusaka, M.D., Yusuke Yoshimoto, M.D., Tsukasa Nishiura, M.D. Abstract ObjectiveSpinal epidural hematomasehis an uncommon clinical entity. Herein, we have described our experiences with cervical SEH patients. Patients and methodsclinical data were obtained for 8 patients men and womenwith cervical SEH and were reviewed retrospectively. The average age of the patients was. yearsrange, 79 years. We evaluated the initial symptoms, history of anticoagulant therapy, preand posttreatment neurological function using the American Spinal Injury AssociationASIAImpairment Scale and Neurosurgical Cervical Spine ScoreNCSS, extent of hematoma and time interval from the initial ictus to the treatment. ResultsSix patients experienced suddenonset neck or upper back pain, and the other patients experienced sudden motor weakness without pain as the initial attack. Four patients had received anticoagulation. One patient had received an analgesic, which may have contained acetylsalicylic acid, for 3 days before the attack, and one patient had coagulopathy due to an unknown cause. Six of the 8 patients presented with severe motor dysfunction or loss of motor functionasia grades A, B, and C. Neurological status in patients improved by at least 1 grade after treatment. The hematoma extended to 5 vertebral segments, but there was no relationship between the extent of hematoma and severity of symptoms. All patients underwent surgical evacuation, and of the 8 patients were treated within 8 h. ConclusionDuring diagnosis in the early stages, it should be noted that the sudden onset of pain during the initial attack does not necessarily occur in all patients with cervical SEH. Our experience with cervical SEH shows that the severity of pretreatment neurological deficits is a reliable predictor of the outcome. ReceivedSeptember, 30, 011acceptedJune, 01 Key words neurological outcome, spinal epidural hematoma, surgical treatment MRI Address reprint requests tokotaro Ogihara, M.D., Department of Neurosurgery, National Hospital Organization, Iwakuni Clinical Center, 51 Kuroisocho, Iwakunishi, Yamaguchi , Japan VOL. NO.01 8
2 Table1Summary of 8 patients with cervical epidural hematoma Case Agesex 5M 7M M 78M F 7M 79M 7F Initial symptoms paraparesis Occipitalgia neck pain Neck pain Neck pain Tetraparesis Left hemiparesis Anticoagulation medication Warfarin Aspirin Ticlopidine Analgesic Ticlopidine Aspirin Clopidogrel sulfate Cilostazol Coagulopathy analgesic that might contain aspirin, unknown cause Pretreatment ASIA gradencss A3 B5 C D8 C D7 B C Posttreatment ASIA gradencss B3 D9 E1 D13 D9 E1 C C Range vertebral segment 5 3 Time interval from symptom onset to treatmenth.5 31 unknown ASIA Impairment Scale Neurosurgical Cervical Spine ScoreNCSS ADL Table ASIA Impairment Scale C ASIA Impairment Scale 1 grade NCSS 8. 5 ASIA Impairment Scale MRI CC mass lesion 5 5 VOL. NO.01 8
3 a c b d Fig. 1 Magnetic resonance imaging of the cervical spine case 3 1 h after an episode of occipitalgia and neck pain a, b and 1 day after hematoma evacuation c, d. a Sagittal T weighted image showing an epidural hematoma extending from the C C vertebrae. b Axial T weighted image showing an epidural hematoma dorsal to the dural sac, with associated cord displacement. c Sagittal and d axial T weighted images showing cord decompression after hematoma evacuation. a c b d Fig. Magnetic resonance imaging of the cervical spine case 7 at least h after an episode of tetraparesis a, b and 53 days after hematoma evacuation c, d. a Sagittal T weighted image showing an epidural hematoma extending from the C vertebra to the C3 disc. b Axial T weighted image showing an epidural hematoma dorsal to the dural sac, with associated cord displacement. c Sagittal and d axial T weighted images showing cord decompression after hematoma evacuation. An intramedullary hyperintense signal on T weighted images was seen at the C3 C disc level. 筋力 右 5 左 5 痛覚は左で低下 深部知覚は右 で 低 下 し て い た Vital sign は 初 診 時 血 圧 ADL は自立していた 前日の夜までは特に変わりなく過 mmhg 脈拍 回 分 酸素飽和度 100 手術直前 ごしていた 朝になっても起きてこないので家人が確認 血圧 13 7 mmhg 脈拍 103 回 分 酸素飽和度 9 で すると四肢が動かず 便尿失禁があったため当院へ救急 あった 搬送された 経 過 入院後 呼吸苦を訴えるようになった 血腫 の上端は C レベルにあり 呼吸苦の原因として呼吸中 枢の圧迫による呼吸障害の可能性があったため 緊急で 現 症 四肢は完全運動麻痺 痛覚 深部知覚は四 肢 体幹で低下していた 経 過 頚椎 MRI で C C3 椎間板レベルで頚髄 発症から.5 時間後 片側椎弓切除下に血腫除去術を 右後外側に T1 強調像で低信号 T 強調像で高信号を呈 行った Fig. 1 術後 症状は改善し 神経脱落症状な する mass lesion を認め Fig. a b 頚髄硬膜外血腫 く退院した と診断した 手術の準備をしつつ経過を厳重に観察した 症例 7 が 症状の改善が得られないため 発症から少なくとも 79 歳 男性 8 時間後に片側椎弓切除下に血腫除去術を行った 術後 主 左上肢の運動麻痺は急速に改善したが 右上肢と両下肢 訴 四肢の脱力 既往歴 脳梗塞の既往があり 抗血小板剤を 3 剤内服 中であった はあるものの実用性なく 歩行不能な状態でリハビリ 現病歴 脳梗塞のため軽度の左片麻痺があったが 0 の運動麻痺の改善は不良であり 右手指 肘関節の自動 脊髄外科 テーション目的で転院となった 術後の MRI では C3 VOL. NO. 01 年 8 月
4 T Fig.cd MRI ,3, , Groen coagulopathy Liao ,10 CT 1,3,,,7 Groen Lawton 8 1 Liao ASIA Impairment Scale Grade BCD Grade A 1 Grade B incomplete spinal dysfunction 8 MRI 1 Connolly 9 Groen 3 VOL. NO.01 8
5 MRI 8 ASIA Impairment Scale C ASIA Impairment Scale A B ASIA Impairment Scale retrospective prospective ASIA Impairment Scale C ASIA Impairment Scale A B Groen RJNonoperative treatment of spontaneous spinal epidural hematomasa review of the literature and a comparison with operative cases. Acta Neurochir Wien , Liao CC, Lee ST, Hsu WC, et alexperience in the surgical management of spontaneous spinal epidural hematoma. J Neurosurg100385, 00 Liao CC, Hsieh PC, Lin TK, et alsurgical treatment of spontaneous spinal epidural hematomaa 5year experience. J Neurosurg Spine11808, 009 7Liu Z, Jiao Q, Xu J, et alspontaneous spinal epidural hematomaanalysis of 3 cases. Surg Neurol953 0, 008 8Lawton MT, Porter RW, Heiserman JE, et alsurgical management of spinal epidural hematomarelationship between surgical timing and neurological outcome. J Neurosurg8317, Connolly ESJ, Winfree CJ, McCormick PCManagement of spinal epidural hematoma after tissue plasminogen activator. A case report. Spine119198, Abram HS, DeLaHunt MJ, Merinbaum DJ, et alrecurrent spontaneous spinal epidural hematoma in a child first case report. Pediatr Neurol , Chen CJ, Fang W, Chen CM, et alspontaneous spinal epidural haematomas with repeated remission and relapse. Neuroradiology , Groen RJ, van Alphen HAOperative treatment of spontaneous spinal epidural hematomasa study of the factors determining postoperative outcome. Neurosurgery , 199 VOL. NO.01 8
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