Spinal epidural hemorrhage is bleeding into the cavity between the inner surface of the walls of the spinal canal and the dural membrane of the spinal cord with the formation of an epidural hematoma. Clinically debuts with intense radicular pain, localized according to the level of hemorrhage, followed by spinal-conduction neurological disorders (paresis, hypesthesia, pelvic dysfunction). It is diagnosed mainly according to MRI of the spine. Treatment in most cases is surgical — laminectomy and aspiration of hematoma. Conservative therapy accompanies the operation or is used independently in the presence of positive dynamics of the process.
General information
Spinal epidural hemorrhage is a separate type of hematomyelia (spinal hemorrhage), in which blood is poured into the epidural space — the gap between the dura mater and the walls of the spinal canal. Spinal epidural hemorrhage associated with spinal injury is called traumatic. The remaining cases are attributed to spontaneous hemorrhages. The prevalence of traumatic epidural hemorrhages is not great, they account for no more than 0.75% of all spinal cord injuries. At a young age, due to increased mobility of the spine, such hemorrhages can occur in the absence of bone damage. The cause of spontaneous epidural hemorrhage can be determined only in 10% of cases. Diagnosis and treatment of spinal hemorrhages are carried out by specialists in the field of neurology, traumatology and neurosurgery.
Causes
Traumatic spinal epidural hemorrhage can be caused by a spinal fracture, vertebral fractures and dislocations, birth trauma, gunshot wounds, spinal contusion. In some cases, it has an iatrogenic genesis and acts as a complication of epidural blockade, spinal surgery, lumbar puncture.
Spontaneous spinal hemorrhage can be caused by disorders in the coagulation system (for example, with hemophilia, thrombocytopenia), anticoagulant treatment, varicose veins of the epidural space, arterial hypertension, abnormalities of the vessels of the epidural space. The latter include aneurysms, arterio-venous fistulas, cavernous malformations and venous anomalies. Vascular malformations are considered the most common cause of epidural spinal bleeding. Triggering factors that cause damage to the epidural vessels may be sharply occurring hypertension in the hollow veins, a sharp rise in intra-abdominal or intra-thoracic pressure.
The factors underlying hemorrhage also include cases of fusion of epidural veins with the periosteum of the spinal canal. In such a situation, with excessive mobility of the spine and increased physical exertion, especially in persons with severe lordosis, tension of the veins occurs, causing their damage. A similar mechanism of hemorrhage can be realized in the presence of adhesions and inflammatory changes in the structures of the spine, which involve the walls of blood vessels. On the other hand, excessive loads on the spine and greater mobility, for example, during extreme sports, can provoke an epidural hemorrhage even in the absence of any predisposing vascular factors.
Symptoms
Spinal epidural hemorrhage manifests itself with sharp pain in the part of the spine where the vascular catastrophe occurred. The pain is similar to the pain of sciatica and is caused by irritation of the spinal roots with blood pouring into the epidural space. After a few hours (sometimes minutes), the pain subsides, spinal-conduction disorders come to the fore. Muscle weakness occurs and progresses, reaching below the level of the lesion of the degree of plegia. There is a decrease in muscle tone, conductive sensory disturbances, a symmetrical decrease in periosteal and tendon reflexes. Pelvic function disorder is characterized by urinary incontinence.
The features of the clinical picture of hemorrhage depend on its location. In patients after the age of 40, in the vast majority of cases, epidural hemorrhages are observed in the lumbar and sacral sections, in persons younger than 40 years – in the cervical and thoracic. Dorsal localization of the formed epidural hematomas prevails.
Diagnostics
When making a preliminary diagnosis, the suddenness of the onset of symptoms, their connection with physical activity, typical stages (pain at first, and then weakness and numbness of the limbs), neurological picture are taken into account. However, it is not possible to establish the diagnosis of epidural hemorrhage only by the clinical picture. An MRI or CT scan of the spine is necessary. MRI of the spine is a more informative method, because it allows you to visualize an epidural hematoma and differentiate it from other shell hemorrhages. In addition, MRI allows you to determine the degree of compression of the spinal cord and identify signs of compression myelopathy. Additionally, vascular CT or magnetic resonance angiography can be performed.
In the absence of the possibility of neuroimaging, lumbar puncture and contrast myelography are performed. Spinal angiography may be used to detect vascular abnormalities, but in the acute period of spinal hemorrhage, this method is usually not used. Epidural spinal hemorrhage should be differentiated from subdural spinal hematoma and subarachnoid spinal hemorrhage, as well as from other lesions: ischemic spinal stroke, acute myelitis, spinal epidural abscess, spinal form of multiple encephalomyelitis, spinal cord tumors, etc.
Treatment
Independent resolution of an epidural spinal hematoma is rarely observed, in this regard, surgical treatment is used in most cases. The operation allows you to quickly eliminate the hematoma and achieve decompression of the spinal cord. Access to the hematoma is carried out by laminectomy. Removal of an epidural hematoma is performed by vacuum aspiration. According to the majority of neurosurgeons, the result of surgical treatment is largely determined by the timeliness of its implementation and the degree of neurological disorders at the time of surgery.
Conservative treatment is carried out by a traumatologist (with traumatic epidural hemorrhage) or a neurologist in cases when the patient was taken to the hospital at a late stage of the disease, and he has a noticeable regression of neurological deficit. It should be said that regression of clinical symptoms and tomographic confirmation of hematoma resorption are indications for conservative therapy, regardless of the timing of hemorrhage. At the same time, conservative measures accompany and complement surgical treatment. Hemocoagulants (aminocaproic acid, vikasol), antihypoxants and neurometabolites (vitamins g B, neostigmine, porcine cerebral hydralizate) are prescribed. In pelvic disorders, catheterization of the bladder and prevention of urogenital infection are performed.
The outcome of epidural spinal bleeding is determined by the timely removal of the resulting epidural hematoma. A favorable prognosis is possible if the operation is performed before the development of a significant neurological deficit, i.e. before the occurrence of irreversible changes in the spinal cord associated with its compression by a hematoma. In other cases, there is a persistent residual neurological deficit in the form of paresis, sensitive disorders, pelvic disorders.