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Delayed Presentation of a Traumatic Spinal Epidural Hematoma in a PreadolescentA Case Report
Andrew A.R. Lehman, MD1; Mark E. McKenna, MD1; Ronald Wisneski, MD1; W. Fred Hess, MD1
1 Department of Orthopaedics, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17821. E-mail address for A.A.R. Lehman: aalehman@geisinger.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at Geisinger Medical Center, Danville, Pennsylvania

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Apr 06;93(7):e28 1-4. doi: 10.2106/JBJS.J.00537
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Spontaneous spinal epidural hematomas are uncommon, with an incidence of 0.1 per 100,000 patients in the general population. In the pediatric population, they are even more uncommon1,2. Symptoms include an acute onset of back or radicular pain followed by a progressive motor paralysis and sensory loss in the lower extremities. There are a limited number of reported cases in children or adolescents1-12.
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    Andrew A.R. Lehman, MD
    Posted on May 20, 2011
    Dr. Lehman and colleagues respond to Dr. Groen and colleagues
    Orthopaedic Surgery Resident, Geisinger Medical Center, Danville, Pennsylvania

    We greatly appreciate the comments shared by Dr. Groen in regard to our report, “Delayed presentation of a traumatic spinal epidural hematoma in a preadolescent” (2011;93:e28). As Dr. Groen pointed out, we omitted information about a post-operative MRI, and therefore our report was in essence incomplete. For this we do apologize.

    A post-operative MRI was obtained for the exact concerns expressed by Dr. Groen. Our patient failed to improve after operative decompression, so it was necessary to rule out a recurrent or persistent epidural hematoma. The MRI, obtained post-operative day one, showed successful evacuation of the epidural hematoma. In regards to the appearance of the spinal cord, there was diffuse increased T2 signal and swelling appreciable in the upper thoracic cord, extending from T1 through T4 levels.

    We hope this helps complete all relevant points of discussion for the reader. We greatly value the opinions of other professionals in the field of spine surgery and again thank Dr. Groen for expressing interest in our rare case.

    Rob J.M. Groen, MD, PhD
    Posted on May 20, 2011
    Delayed Presentation of a Traumatic Spinal Epidural Hematoma in a Pre-Adolescent
    Neurosurgeon, University Medical Center Groningen, The Netherlands

    To the Editor:

    We read with much interest the report, "Delayed presentation of a traumatic spinal epidural hematoma in a pre-adolescent" (2011;93:e28) by Lehman et al. As the authors pointed out, spinal epidural hematomas are rare, and in the pediatric population such a condition is even more rare. The clinical course of a spinal epidural hemorrhage often is serious, with acute back or neck pain, followed by a rapid development of severe spinal cord compression symptoms. Early diagnosis is needed, and urgent surgical decompression is the mainstay of treatment in the majority of cases. Postoperative improvement has been shown to relate to the severity of preoperative neurological deficit, operative interval, and the site (vertebral segment) of the hematoma (1). Most of these hematomas are "spontaneous" of origin, in the absence of tumor/neoplasm, fracture, vascular anomaly or spinal intervention (operation, puncture) (2).

    In the present report, the patient suffered a minor trauma, three weeks before the occurrence of the neurological deficit. This is typical for the so-called spontaneous spinal epidural hematoma (SSEH). Traumatic SEHs are related to surgical procedures, severe trauma with fractures and dislocation (though extremely rare), which definitely was not the case in this boy. As such, the title of the paper is incorrect, referring to a traumatic origin, instead of the "spontaneous" nature. MR images after presentation, while paraplegic, revealed an acute postero-lateral epidural hematoma at C7-T4. This is consistent with the onset of cord compression symptoms earlier that day. This means that the term “delayed” in the title likewise is questionable; it is very unlikely that neurological symptoms would follow after several days, with such a large hematoma.

    Despite of prompt surgical treatment (cord decompression and removal of the hematoma were performed approximately nine hours after the onset of paralysis [which is in favor of postoperative recovery (1)), the patient did not improve (FU at 8 months after operation). For the readership it is essential to know whether a postoperative (recurrent) hematoma has been ruled out, and whether spinal cord decompression has been confirmed with postoperative MR imaging. However, no information as such is presented, which to our opinion is an omission. Publication of rare and serious conditions like SSEH is of great importance, both to alert and to educate the medical community. From the didactical point of view, proper documentation and discussion of all the relevant issues is needed. The main point that we would like to make is that post-operative imaging, especially in a case of SSEH that does not improve after (rapid/early) operative treatment, has to be part of the surgical routine. What triggered us most in this context is the fact that the authors describe in their paper that closure of the operative field was performed while bleeding was not completely under control. Did they rule out recurrent and/or sustained spinal cord compression? In order to clarify this, it would be helpful if the authors would respond in a reply, completing their report with the presentation of the early postoperative MR images.

    References

    1. Groen RJM, Alphen van HAM. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery 1996;39:484-509.

    2. Groen RJM, Ponssen H. The spontaneous spinal epidural hematoma. A study of the etiology. J Neurol Sci. 1990;98:121-38.

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