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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 2  |  Page : 205-207

Spontaneous spinal epidural hematoma: A rare cause of paraplegia in pregnancy


Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Panchasayar, Kolkata, West Bengal, India

Date of Submission01-May-2013
Date of Decision02-May-2013
Date of Acceptance31-Mar-2014
Date of Web Publication14-May-2014

Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Panchasayar, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.132413

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How to cite this article:
Krishnan P, Kartikueyan R. Spontaneous spinal epidural hematoma: A rare cause of paraplegia in pregnancy. Neurol India 2014;62:205-7

How to cite this URL:
Krishnan P, Kartikueyan R. Spontaneous spinal epidural hematoma: A rare cause of paraplegia in pregnancy. Neurol India [serial online] 2014 [cited 2021 May 15];62:205-7. Available from: https://www.neurologyindia.com/text.asp?2014/62/2/205/132413


Sir,

A 25-year-old pregnant lady (27-weeks gestation) presented with sudden onset severe interscapular pain of 2-day duration. She developed weakness of both lower limbs and retention of urine overnight. On examination, lower limb power bilaterally was Grade 0/5 except a flicker of movement in the right ankle dorsiflexors. All deep tendon reflexes were absent. Sensations were preserved in the lower limbs. Plantar response was bilaterally mute. There was mild tenderness over the upper dorsal spine. Fetal heart sounds were present. Magnetic resonance imaging (MRI) of dorsal spine revealed a dorsal spinal epidural hematoma (SEH) extending from D3 to D6 levels with cord compression [Figure 1] and [Figure 2]. A decision was taken to proceed with dorsal laminectomy and clot evacuation and allow the pregnancy to continue as she was only in the second trimester. She was given steroids to boost fetal lung maturation (in case of preterm labor) and was put on uterine relaxants. She underwent D3-D6 laminectomy with evacuation of epidural hematoma and decompression of thecal sac under general anesthesia (GA) in the right lateral position. Postoperatively she regained lower limb power and in 2 weeks was able to stand with support and became continent. Her pregnancy continued till term. At 41 weeks she delivered a healthy child via cesarean section. At 8 months follow-up she had no deficits.
Figure 1: T2-weighted sagittal image of the dorsal spine showing an epidural hematoma located dorsal to the cord extending from D3 to D6 levels causing obliteration of the spinal subarachnoid space and pushing the cord anteriorly against the vertebral bodies

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Figure 2: T1-weighted axial image showing isointense clot located dorsal to the cord pushing it anteriorly and to the left. Hyperintense intraspinal fat and hypointense thecal CSF can no longer be seen CSF = Cerebrospinal fluid

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SEH is a rare condition [1],[2],[3] accounting for less than 1% of all epidural compressive pathologies. [4] Traumatic and iatrogenic causes apart, it has been reported in the setting of coagulopathies, [1] arteriovenous malformations [AVM's], [3],[4] anticoagulant therapy, [3],[4] and following prolonged Valsalva maneuvers. [3] Pregnancy has been described as a risk factor [3],[5] for idiopathic SEH as raised intra-abdominal pressure forces venous return from the pelvis and abdomen through the valveless vertebral venous plexus. Rupture of these thin-walled veins has been cited as the reason for the hemorrhage. [1],[4],[6] We describe the cases we found in literature with relevant data in [Table 1].
Table 1: Reports of previous cases described in literature with clinical details, level of involvement, time to presentation, relationship of clot evacuation with delivery, and outcome[1,2,4,6-9]

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Typically these patients present with acute onset spinal pain [4] followed by neurological deficit occurring within hours. The common location of the hematoma, as in our case, is in the dorsal spine. [4] The speculated reason is the rich epidural plexus present in this region. [7] While two cases of ventral location of the SEH were described, the vast majority like in our case are located dorsally. [1],[6] This is because the anterior aspect of the thecal sac is adherent to the posterior longitudinal ligament, whereas posteriorly there is a potential space between the lamina and the dura filled by the epidural fat. [6] MRI is the diagnostic modality of choice, [4],[7] as it helps to confirms the diagnosis, delineates the location of the clot (both with respect to level and position relative to the thecal sac), and can identify cord signal changes that could be of predictive value regarding neurological improvement. The treatment option is an urgent spinal decompression and clot evacuation as the modality of treatment. [4],[7] Conventional laminectomy with gentle removal of the clot has been recommended. [4] There are no intraoperative reports that suggest finding an AVM. Our patient too underwent a laminectomy and clot evacuation. Prognosis in terms of neurological recovery is determined by the extent of preoperative neurological compromise (incomplete injuries recovering better) and time elapsed from onset of neurological symptoms to surgery, longer time durations having poorer prognosis. [1],[4],[7] Our patient was fortunate in that she became paraplegic during the hospital stay, and we were able to operate on her within 8 h of symptom onset.

The issue of continuation of pregnancy is a matter of concern in case like ours who presented at 27 weeks of gestation. Majority of patients described presented in third trimester (mean gestational age 33.2 weeks) [2] , where fetal maturity was not an issue and underwent emergency cesarean section followed by clot evacuation [Table 1]. This had the advantage of decreasing the intra-abdominal pressure, resulting in less epidural venous distention and less intraoperative bleeding. [4] Moreover spinal surgery could then be done in the conventional prone position-a fact that would not be possible if the pregnancy was continuing. In our case too we had to opt for the latter, and the patient had to be operated on lateral position. Where fetal maturity is a problem, steroids have been recommended to increase lung maturation. [4] Systemic steroids may have a beneficial effect on the cord as well, and hence in our case we felt it logical to administer the same. To prevent risk of precipitate labor in the postoperative period, our patient was given uterine relaxants for 14 days after surgery as well.

To conclude SEH, though rare, must be kept in mind in pregnant women with sudden onset severe spinal pain and rapidly progressive neurological deficits, as an emergent surgical evacuation is associated with good functional recovery.


  Acknowledgments Top


The authors are grateful to Dr. Rupak Ranjan Roy (Consultant Gynecologist) and Dr. Sanjukta De (Consultant Pediatrician) who contributed in the clinical care of this patient.[9]

 
  References Top

1.Steinmetz MP, Kalfas IH, Willis B, Chalavi A, Harlan RC. Successful surgical management of a case of spontaneous epidural hematoma of the spine during pregnancy. Spine J 2003;3:539-42.  Back to cited text no. 1
    
2.Henry JB, Messerer M, Thomas V, Diabira S, Morandi X, Hamlat A. Nontraumatic spinal epidural hematoma during pregnancy: Diagnosis and management concerns. Spinal Cord 2012;50:655-90.  Back to cited text no. 2
    
3.Solero CL, Fornari M, Savoiardo M. Spontaneous spinal epidural hematoma arising from ruptured vascular malformation. Case report. Acta Neurochir (Wein) 1980;53:169-74.  Back to cited text no. 3
    
4.Wang P, Xin XT, Lan H, Chen C, Liu B. Spontaneous cervical epidural hematoma during pregnancy: Case report and literature review. Eur Spine J 2011;20:S176-9.  Back to cited text no. 4
    
5.Matsubara S. Spontaneous spinal epidural hematoma during pregnancy. Arq Neuropsiquiatr 2012;70:81.  Back to cited text no. 5
[PUBMED]    
6.Badar F, Kirmani S, Rashid M, Azfar SF, Yasmeen S, Ullah E. Spontaneous spinal epidural hematoma during pregnancy: A rare obstetric emergency. Emerg Radiol 2011;18:433-6.  Back to cited text no. 6
    
7.Szkup P, Stoneham G. Case report: Spontaneous spinal epidural hematoma during pregnancy: Case report and review of the literature. Br J Radiol 2004;77:881-4.  Back to cited text no. 7
    
8.Miguil M, Mounir A, El Benny M, Moussaid I, Salmi S. Spontaneous thoracic epidural hematoma during pregnancy: Another Case! J Anesth Clin Res 2012;3:208.  Back to cited text no. 8
    
9.Wang ZL, Bai HX, Yang L. Spontaneous spinal epidural hematoma during pregnancy: Case report and literature review. Neurol India 2013;61:436-7.  Back to cited text no. 9
[PUBMED]  Medknow Journal  


    Figures

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    Tables

  [Table 1]

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