Case Report

Spontaneous epidural hematoma of the thoracic spine in a 17-year-old Adolescent boy: a case report

Abstract

Spontaneous spinal epidural hematoma is a rare cause of Spinal cord compression. Symptoms typically include a sudden onset of back pain followed by Neurologic deterioration including weakness, numbness, and incon- tinence. We report the case of a 17-year-old adolescent boy who presented to the emergency department with acute onset of back pain that woke him from sleep, progressing to paralysis and anesthesia of lower extremities, accompanied by priapism. Magnetic resonance imaging (MRI) demon- strated an epidural hematoma of the thoracic spine with spinal cord compression. The patient was taken to the operating room for decompression laminectomy where they discovered a thrombosed dural arteriovenous fistula. Post- operative angiography shows no residual lesions. Emer- gency physicians see many patients with back pain and should be clinically suspicious of spontaneous spinal epidural hematomas to reduce morbidity and mortality.

Spontaneous spinal epidural hematoma is a rare cause of spinal cord compression. Symptoms typically include a sudden onset of back pain followed by neurologic deteriora- tion including weakness, numbness, and incontinence. Emergency physicians should be aware of this diagnosis so that they may treat appropriately and avoid long-term neurologic deficits.

A 17-year-old adolescent boy was brought to the ED by EMS with a complaint of back pain and inability to move his legs. The patient reported being woken from sleep with a severe back pain 2 hours earlier. Pain was described as dull and achy initially and then became similar to a cramp or Muscle spasm. The patient tried to stretch his back by lying on the ground and pulling his knees to his chest. When this did not relieve his pain he took a warm shower, after which his pain became sharp and burning. He woke his parents and laid down on their bed where he developed an ascending weakness and numbness that turned into complete paralysis and insensate lower extremities with a persistent erection.

On arrival, he was conscious, alert, with no respiratory distress and normal vitals. Medical history included acne for

which he was being treated with an unknown antibiotic. The patient and his family denied recent trauma, drug use, or a family history of vascular problems. The patient reported having had a recent upper respiratory infection approxi- mately 2 weeks before. He complained of a severe burning pain in his mid back. Upon examination, the patient had an unremarkable head, ears, eyes, nose, throat, lung, and cardiovascular examination. Abdomen was soft, nontender, and not distended. No sensation was noted below the level of T6, and the patient’s lower extremities exhibited 0/5 strength bilaterally. Increased tone and brisk patellar reflexes were noted in the lower extremities bilaterally, and active priapism with normal rectal tone was also noted.

On examination approximately 20 minutes after initial presentation, the patient’s lower extremities were noted to be flaccid and areflexic. The patient’s vital signs remained unchanged with no signs of respiratory depression. Neuro- surgical and neurology consultants were contacted and an emergent MRI was ordered. Methylprednisolone 250 mg IV was administered. Initial laboratory tests including a complete blood count, chemistry panel, and coagulation profile were all within normal limits.

Magnetic resonance imaging demonstrated an acute epidural hematoma within the posterior and posterior left lateral epidural Spinal canal at the T2 through T3 level with associated spinal cord compression. Measurement of the lesion was 4.5 cm in maximal superior-inferior diameter and 1.6 x 1 cm in cross-sectional diameter. The patient was taken to the operating room for emergent decompression laminectomy approximately 260 minutes after arrival and 360 minutes after the initial onset of symptoms. During the surgery, the hematoma was evacuated and the patient was found to have a thrombosed dural AV fistula. The dilated veins on the dura were coagulated and divided during the surgery, and post- operative angiography showed no residual lesion. Upon discharge to an acute spinal cord injury inpatient rehabilitation center, the patient had regained sensation and full strength but required assistance with ambulation due to poor balance and coordination. The patient also exhibited Urinary retention requiring self-catheterization and moderate constipation requiring medication.

A healthy, young male with acute onset of back pain followed by neurologic deficits was diagnosed with a

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spontaneous spinal epidural hematoma, which is a rare cause of this clinical presentation. Spontaneous spinal epidural hematoma is defined as an accumulation of blood in the vertebral epidural space that has no obvious cause [1]. Spontaneous spinal epidural hematoma represents 40% to 50% of all spinal epidural hematomas [2].

The pathogenesis is unclear but the bleeding is assumed to be of venous origin, occurring in the valveless epidural venous plexus that is vulnerable to variations in pressure from the abdominal and thoracic cavities. Hematomas are usually located posterior to the spinal cord, which is consistent with the anatomical location of the venous plexus [2]. Most cases (20%-35%) are caused by anticoagulant use [2]. Other causes include epidural injection, minor trauma, arteriovenous malformations, and activities requiring valsalva, such as coughing and trumpet playing [2-5]. Spontaneous spinal epidural hematoma occurs in all age groups, most frequently after the fourth or fifth decade of life and is rare in children [2,6,7]. There is a 1.4:1 male preponderance, and the location of the lesion varies with age [7]. Most common locations in adults include the cervicothoracic junction for those younger than 40 years and the thoracolumbar junction for those 40 to 80 years of age, whereas in children it is the C5-T1 region [2,7].

Patients typically present with an acute onset of localized pain, sometimes accompanied by paresthesias in a radicular pattern. Progression to symptoms of spinal cord compression (sensorimotor deficit) typically occurs within hours.

Spontaneous spinal epidural hematoma is a neurosurgical emergency requiring surgical intervention, although there are cases of conservative management with full resolution of symptoms [2,8,9]. Evaluation of a patient with these findings in the ED should be thorough but also rapid. Laboratory testing and imaging should be obtained quickly to rule out other possible diagnoses. The Imaging study of choice for Spontaneous spinal epidural hematoma is MRI. Neurosur- gery should be consulted when considering this diagnosis. Factors affecting prognosis include time to operative intervention (b48 hours), severity of neurologic deficit and level of deficit [2,10]. Neurologic outcome is not affected by patient age, sex or size of hematoma [10].

Back pain is one of the most common complaints seen in the ED. If emergency physicians keep this disease process in their differential diagnosis of Acute back pain, they may be able to make an early diagnosis, decrease morbidity, and improve prognosis.

Sarah Lannum MD Department of Emergency Medicine St. Luke’s Roosevelt Hospital Center

NY 10019, USA

E-mail address: [email protected]

Jennifer Stratton MD Department of Emergency Medicine St. Luke’s Roosevelt Hospital Center

NY 10019, USA

doi:10.1016/j.ajem.2008.08.031

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