Acute spinal subdural hematoma complicating lumbar decompressive surgery

ABSTRACT

Study design: A case report.

Objective: To report a rare case of acute spinal subdural hematoma (SSH) complicating lumbar spine surgery, its characteristic presenting symptoms, diagnostic imaging, possible cause, and pitfall in management.

Methods: A 59-year-old woman with lumbar spinal instability and stenosis underwent laminectomy and decompression at L3-L5 with instrumentation and fusion from L3-S1.

Results: Immediately following surgery, the patient presented with incapacitating pain of both lower extremities from the mid-thigh downward, which was not relieved by narcotic analgesia and was disproportional to surgical trauma. Left ankle and great toes weakness was detected at postoperative day 2 and deteriorated on day 6. Magnetic resonance imaging was performed urgently and revealed a characteristic SSH with thecal sac compression at the level of L2, proximal to the laminectomy. Emergency decompression and evacuation of the hematoma was performed. The patient had partial recovery 6 weeks postoperatively.

Conclusion: Acute SSH is a rare complication of lumbar spine surgery. This diagnosis must be considered when severe leg pain, unresolved with analgesia and disproportional to surgical trauma, with neurological deterioration occurring after lumbar spine surgery. Magnetic resonance imaging is the imaging modality of choice to assist in the differential diagnosis of an SSH. Early surgical decompression is necessary for optimal neurological recovery.

• REFERENCES

• 1 Gehri R, Zanetti M, Boos N. 2000; Subacute subdural haematoma complicating lumbar microdiscectomy. J Bone Joint Surg Br 82 (7) 1042-1045
• 2 Reinsel TE, Goldberg E, Granato DB et al. 1993; Spinal subdural hematoma: a rare cause of recurrent postoperative radiculopathy. J Spinal Disord 6 (1) 62-67
• 3 Jain V, Singh J, Sharma R. 2008; Spontaneous concomitant cranial and spinal subdural haematomas with spontaneous resolution. Singapore Med J 49 (2) e53-58
• 4 Yang MS, Tung YW, Yang TH et al. 2009; Spontaneous spinal and intracranial subdural hematoma. J Formos Med Assoc 108 (3) 258-261
• 5 Chau SY, Tiu SC. 2008; Spinal subdural haematoma: a rare complication of low-molecular-weight heparin therapy. Hong Kong Med J 14 (1) 64-66
• 6 Jonsson LO, Einarsson P, Olsson GL. 1983; Subdural haematoma and spinal anaesthesia; a case report and an incidence study. Anaesthesia 38 (2) 144-146
• 7 Edelson RN, Chernik NL, Posner JB. 1974; Spinal subdural hematomas complicating lumbar puncture. Arch Neurol 31 (2) 134-137
• 8 Kulkarni AV, Willinsky RA, Gray T et al. 1998; Serial magnetic resonance imaging findings for a spontaneously resolving spinal subdural hematoma: case report. Neurosurgery 42 (2) 398-400 discussion 400–391
• 9 Post MJ, Becerra JL, Madsen PW et al. 1994; Acute spinal subdural hematoma: MR and CT findings with pathologic correlates. AJNR Am J Neuroradiol 15 (10) 1895-1905

• REFERENCES EDITORIAL PERSPECTIVE

• 1 Goodkin R, Laska LL. 1995; Unintended “incidental” durotomy during surgery of the lumbar spine: medicolegal implications. Surg Neurol 43: 4-14
• 2 Kostuik JP. 2004; Medicolegal consequences of cauda equina syndrome: an overview. Neurosurg Focus 16 (6) 39-41

• REFERENCES COMMENTARY

• 1 Gehri R, Zanetti M, Boos N. 2000; Subacute subdural haematoma complicating lumbar microdiscectomy. J Bone Joint Surg Br 82 (7) 1042-1045
• 2 Reinsel TE, Goldberg E, Granato DB et al. 1993; Spinal subdural haematoma: a rare cause of recurrent postoperative radiculopathy. J Spinal Disord 6 (1) 62-67
• 3 Morandi X, Riffaud L, Chabert E et al. 2001; Acute nontraumatic spinal subdural hematomas in three patients. Spine (Phila Pa 1976) 26 (23) E547-551