Article, Neurology

Spontaneous spinal epidural hematoma presenting as flank pain and constipation

Case Report

Spontaneous spinal epidural hematoma presenting as flank pain and constipation

Abstract

We report a case of a Spontaneous spinal epidural hematoma presenting as constipation and flank pain in a patient on warfarin. The patient initially complained of these symptoms and was evaluated for renal colic or an aortic aneurysm. On the patient’s second emergency department visit, he developed progressive paralysis and never regained neurological function. An adynamic ileus causing constipa- tion may have been an early neurological finding in the patient’s presentation. This case report illustrates a critical diagnosis to consider in the evaluation of an anticoagulated patient with flank or back pain.

Spontaneous spinal epidural hematoma (SSEH) is a rarely encountered pathology in the emergency department (ED) but one that carries high morbidity. The incidence is estimated at approximately 1 per 1 million individuals [1,2]. Typical symptoms include the sudden onset of back pain with rapidly progressing Neurological deficits. We report a case of SSEH in an anticoagulated patient that presented with acute flank pain and constipation.

A 58-year-old man presented to the ED with a chief complaint of severe and sudden-onset, right-sided flank pain. The pain was constant and started 2 days ago. He denied any injury, weakness, or numbness. His only other complaint was constipation for 2 days. His past medical history was pertinent for hypertension, diabetes, atrial fibrillation, stroke, and congestive heart failure. His pertinent medications included aspirin, losartan, warfarin, furosemide, and insulin. On examination, his blood pressure was 191/103 mm Hg, heart rate 109, temperature 36.9?C, and respiratory rate 19. He was in moderate distress. His abdominal, rectal, and Neurological examinations were noted to be within normal limits. Examination of his back revealed no ecchymosis,

tenderness to palpation, or costovertebral angle tenderness.

Complete blood count, electrolytes, and urinalysis were within normal limits. The patient’s International normalized ratio was 2.56. Computerized tomography imaging of the abdomen was unremarkable, demonstrating no evidence for hydronephrosis, renal stones, aortic aneurysm, or Retroperitoneal hematoma (Fig. 1).

The patient’s pain improved with analgesia, and his constipation was relieved with an enema. He was discharged home with the diagnoses of Musculoskeletal pain and constipation.

He returned to the ED 2 days later with worsening right- sided flank pain as well as persistent constipation. His physical examination and laboratories were unchanged from the prior visit. Despite receiving repeat doses of opiates for pain, he did not improve and was admitted to the hospital for intravenous analgesia. Shortly into his hospital course, the patient developed sudden-onset numbness and weakness of his bilateral lower extremities that rapidly progressed to full paralysis. Emergent magnetic resonance imaging (MRI) revealed a posterior spinal epidural hematoma that extended from T8-L2 with cord and thecal sac compression (Figs. 2 and 3). Because of his elevated (INR), there was a delay in an operative intervention, and he failed to regain any motor or sensory function. He continued to experience severe constipation, which was attributed to an adynamic ileus from his spinal cord lesion.

The most common etiology of spinal epidural hematomas is direct trauma or invasive procedures. Nonetheless, spontaneous hematomas arise in the setting of specific risk factors [3-5]. These include anticoagulation therapy, preg- nancy, hypertension, and spinal manipulation. Several authors have argued that the fragility of the spinal venous plexus is a key contributing factor [2,6]. They postulate that increased pressure, such as that which a Valsalva maneuver may create, may trigger the plexus to bleed in patients at risk. This mechanism has been disputed by others because the intrathecal pressure is normally higher than the pressure present in the venous plexus. Some postulate that bleeding must therefore be arterial [7].

The typical clinical presentation of SSEH is the sudden onset of severe back pain followed by progressive neurological deficits. The pain may migrate along a dermatome or be accompanied with a radicular component. It is notable that the back pain can arise from any spinal level, but there is a predisposition for the cervicothoracic or the thoracolumbar regions [2]. Although the patient described in this report did not have primary back pain, his flank pain represented probable migration down lower- thoracic dermatomes.

Neurological deficits may begin as paresthesias and progress to weakness, autonomic deficits, and more

0735-6757/$ – see front matter (C) 2010

536.e4 Case Report

Fig. 1 Sagittal CT image of spine and aorta. No abnormalities are detected.

pronounced sensory deficits. Delays in the onset of neurological symptoms as well as cases of relapsing neurological symptoms have been reported [8-10]. Ady- namic ileus is a well-recognized complication of acute spinal cord lesions [10,11]. Constipation from an adynamic ileus may have been the only initial neurological deficit in the patient we present in this report.

Fig. 2 Sagittal T2-weighted MRI image of thoracic spine with posterior epidural hematoma. Arrows indicate epidural hematoma posterior to the T11 vertebral body and spinal cord.

Fig. 3 Axial T2-weighted MRI image of lumber spine with posterior epidural hematoma. Arrows indicate epidural hematoma posterior to the L2 vertebral body and spinal cord.

The differential diagnosis for SSEH includes Epidural abscess, acute vertebral disc disease, cauda equina syn- drome, malignancy, Occult fractures, and spinal ischemia. The diagnostic method of choice is MRI. Plain radiographic films may assist in ruling out other etiologies of back pain but are unable to assess for epidural hematomas. Spinal CT imaging without myelography has poor sensitivity for detecting SSEH. The prognosis of SSEH is largely dependent on the period between the onset of symptoms and Surgical decompression [12]. Although spontaneous resolution is reported in the literature, emergent surgical decompression is indicated for most cases [13,14]. In the patient we describe, the neurological deficits were too dense to expect a significant improvement after decompression.

In conclusion, SSEH is a rare but critical diagnosis to consider in anticoagulated patients with flank or back pain. Attention to subtle neurological symptoms, such as the constipation that was present in this case, can heighten awareness to this diagnosis.

Joseph B. Miller MD

Department of Emergency Medicine

Henry Ford Hospital Detroit, MI 48202, USA

E-mail address: [email protected]

Gurujot Khalsa MD Department of Emergency Medicine Veteran Affairs Medical Center Albuquerque, NM 87108, USA

Case Report 536.e5

Taher Vohra MD

Department of Emergency Medicine

Henry Ford Hospital Detroit, MI 48202, USA

doi:10.1016/j.ajem.2009.04.018

References

  1. Holtas S, Heiling M, Lonntoft M. Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 1996;199:409-13.
  2. Groen RJM, Ponssen H. The spontaneous spinal epidural hematoma: a study of the etiology. J Neurol Sci 1990;98:121-38.
  3. Spengos K, Sameli S, Tsivvgoulis G, et al. Spontaneous spinal epidural hematoma in an untreated Hypertensive patient. Eur J Intern Med 2005; 16:451-3.
  4. Jea A, Moza K, Levi AD, et al. Spontaneous spinal epidural hematoma during pregnancy: case report and literature review. Neurosurgery 2005;56(5):1156.
  5. Niedhart CH. Chiropractic manipulation and spinal epidural hematoma

–what came first? Z Orthop Ihre Grenzgeb 2004;142(5):631-2.

  1. Groen RJM, Ponssen H. Vascular anatomy of the spinal epidural space; considerations on the etiology of the spontaneous spinal epidural hematoma. Clin Anat 1991;4:413-20.
  2. Henderson RD, Pittock SJ, Piepgras DG, et al. Acute spontaneous spinal epidural hematoma. Arch Neurol 2001;58:1145-6.
  3. Dinsmore AJ, Leonard RB, Manthey D. Spontaneous spinal epidural hematoma: a case report. J Emerg Med 2005;28(4):423-6.
  4. Sano H, Satomi K, Hirano J. Recurrent idiopathic epidural hematoma: a case report. J Orthop Sci 2004;9(6):625-8.
  5. Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26(1):1-49.
  6. Lynch AC, Antony A, Dobbs BR, et al. Bowel dysfunction following spinal cord injury. Spinal Cord 2001;39:193-203.
  7. Groen RJM, Alphen HAM. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurg 1996;39:494-508.
  8. Jan W, Beggs I. A pain in the back! Brit journ Rad 1999;72:99-100.
  9. Schroder J, Plakovic S, Wassmann H. Spontaneous spinal epidural haematoma: a therapeutical challenge? Report of an unusual case. Emerg Med J 2005;22(5):387-8.