- Overview of Spinal Cord Disorders
- Acute Transverse Myelitis
- Cauda Equina Syndrome
- Cervical Spondylosis and Spondylotic Cervical Myelopathy
- Hereditary Spastic Paraplegia
- Spinal Cord Arteriovenous Malformations (AVMs)
- Spinal Cord Autonomic Dysreflexia
- Spinal Cord Compression
- Spinal Cord Infarction
- Spinal Epidural Abscess
- Spinal Subdural or Epidural Hematoma
- Subacute Combined Degeneration
- Syrinx of the Spinal Cord or Brain Stem
- HTLV-1–Associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP)
A spinal subdural or epidural hematoma is an accumulation of blood in the subdural or epidural space that can mechanically compress the spinal cord. Diagnosis is by MRI or, if not immediately available, by CT myelography. Treatment is with immediate surgical drainage.
(See also Overview of Spinal Cord Disorders.)
Spinal subdural or epidural hematoma (usually thoracic or lumbar) is rare but may result from back trauma, anticoagulant or thrombolytic therapy, or, in patients with bleeding diatheses, lumbar puncture.
Symptoms and Signs of Spinal Subdural or Epidural Hematoma
Symptoms of a spinal subdural or epidural hematoma begin with local or radicular back pain and percussion tenderness; they are often severe.
Spinal cord compression may develop; compression of lumbar spinal roots may cause cauda equina syndrome and lower-extremity paresis. Deficits progress over minutes to hours.
Diagnosis of Spinal Subdural or Epidural Hematoma
MRI
Hematoma is suspected in patients with symptoms and signs of acute, nontraumatic spinal cord compression or sudden, unexplained lower extremity paresis, particularly if a possible cause (eg, trauma, bleeding diathesis) is present.
Diagnosis of a spinal subdural or epidural hematoma is by MRI or, if MRI is not immediately available, by CT myelography.
Treatment of Spinal Subdural or Epidural Hematoma
Drainage
Treatment of a spinal subdural or epidural hematoma is immediate surgical drainage.
Discontinue any anticoagulant therapy. Patients taking vitamin K antagonist anticoagulants (eg, warfarin) are given phytonadione (vitamin K1) and four-factor prothrombin complex concentrate (PCC). If PCC is not available, fresh frozen plasma is administered as needed to normalize the INR (international normalized ratio). Phytonadione is given IV if urgent treatment is needed; it is given orally if treatment is not urgently needed. Patients taking direct thrombin inhibitors (eg, dabigatran) are given idarucizumab or four-factor PCC. Anticoagulation with direct factor Xa inhibitors (eg, apixaban, rivaroxaban) can be reversed with andexanet alfa or four-factor PCC. Discontinue any anticoagulant therapy. Patients taking vitamin K antagonist anticoagulants (eg, warfarin) are given phytonadione (vitamin K1) and four-factor prothrombin complex concentrate (PCC). If PCC is not available, fresh frozen plasma is administered as needed to normalize the INR (international normalized ratio). Phytonadione is given IV if urgent treatment is needed; it is given orally if treatment is not urgently needed. Patients taking direct thrombin inhibitors (eg, dabigatran) are given idarucizumab or four-factor PCC. Anticoagulation with direct factor Xa inhibitors (eg, apixaban, rivaroxaban) can be reversed with andexanet alfa or four-factor PCC.
Patients with thrombocytopenia are given platelets.
Key Points
Suspect spinal subdural or epidural hematoma in patients with local or radicular back pain and percussion tenderness or sudden, unexplained lower-extremity paresis, particularly if a possible cause (eg, trauma, bleeding diathesis) is present.
Diagnose using MRI or, if MRI is not immediately available, CT myelography.
Immediately drain the hematoma surgically.
