Definition
- Epidural haemorrhages that are not associated with structural vascular lesions are usually the result of anticoagulant use.
Numbers
- Responsible for up to 11.8% of nontraumatic spinal cord injury
Location
- Cervicothoracic spine, with 2-4 spinal segments most commonly involved.
Aetiology
- Anticoagulants
- It is not presently known how the introduction of novel oral anticoagulants (NOACs) will affect its incidence.
- Furlan et al 2012: Systematic review n=553 reported patients with spontaneous central nervous system (CNS) haemorrhage
- SESH patients were significantly younger.
- Some 88% underwent surgical decompression with death and good recoveries each accounting for 21% of outcomes in an admittedly small cohort.
- Manage it like spinal cord trauma
Clinical presentation
- Intense, stabbing pain at the location of the hemorrhage (“coup de poignard of Michon”) that may be followed in some cases by a pain-free interval of minutes to days, after which there is progressive paralysis below the affected spinal level.
Radiology
- MR
- Lentiform collection in the epidural compartment
- The signal intensity of which will vary with the age of the hemorrhage
- Fat-suppressed T1WI can be used to distinguish blood from fat
Surgery
- Early surgical decompression
- Is standard
- If exact location of the hematoma cannot be detected and confirmed by MRI
- The dura should be opened to exclude a subdural hematoma.
- Conservative treatment
- Has also been documented, usually when neurological deficits improved in the early phase or with the coexistence of coagulopathy and multilevel acute epidural hematomas.
Post-operative outcome
- Operation type
- Decompressive laminectomy and hemi-laminectomy have been reported as equally effective for clot evacuation, with no significant risk for spinal instability in lesions spanning up to 5 levels
- Those with hemilaminectomy with better outcome esp if doing > 5 levels of decompression
- Pre-operative neurologic status
- 70-80% improve regardless of initial ASIA grade
- Use of warfarin
- Operative interval < 12 hrs