CASE REPORT cervical spinal epidural hematoma
A c u t e T r a u m a t i c Cervical Epidural H e m a t o m a From a Stab Wound Cervical spinal epidural hematoma is an infrequent entity that usually requires emergency decompressive therapy because of rapid neurologic dysfunction. We present the case of a 34-year-old man who presented to the emergency department with mirlimal symptomatology after a stab wound to the neck. A computed tomography myelogram of the cervical spine revealed a cervical spinal epidural hematoma. This case illustrates an unusual presentation as well as etiology of cervical spinal epidural hematoma. [Olshaker JS, Barish RA: Acute traumatic cervical epiduraI hematoma from a stab wound. Ann Emerg Med June 1991;20:662-664.] INTRODUCTION Spinal epidura] h e m a t o m a is an u n c o m m o n e n t i t y that u s u a l l y occurs from spontaneous causes, but is occasionally due to trauma. It is u s u a l l y associated w i t h rapid progression of neurologic deficits requiring surgical decompression. Its early diagnosis and t r e a t m e n t is essential for a good outcome. On review of the literature, this appears to be the first case report of a cervical spinal epidural h e m a t o m a from a stab wound. This case is also u n u s u a l in the p a u c i t y of signs and s y m p t o m s the patient experienced.
Jonathan S OIshaker, MD, FACEP Robert A Barish, MD, FACEP Baltimore, Maryland From the Division of Emergency Medicine, Department of Surgery, University of Maryland Medical System, Baltimore. Received for publication October 19, 1990. Accepted for publication January 3, 1991. Address for reprints: Jonathan S Olshaker, MD, FACER Division of Emergency Medicine, Department of Surgery, University of Maryland Medical System, 22 South Greene Street, Baltimore, Maryland 21201.
CASE REPORT A 34-year-old m a n presented to the e m e r g e n c y d e p a r t m e n t w i t h the history of being stabbed twice in the neck three hours earlier by a female acquaintance, He denied loss of consciousness, head trauma, or any other injuries. He i n i t i a l l y c o m p l a i n e d of only m i l d soreness at the site of the w o u n d on the back of his neck. On repeated questioning during the physical e x a m i n a t i o n he did a d m i t that his right t h u m b had felt n u m b since shortly after the assault. His medical h i s t o r y was r e m a r k a b l e only for an a d m i s s i o n two years earlier for esophageal varices. He was on no m e d i c a t i o n s and had no allergies. He a d m i t t e d to occasional alcohol use. His last tetanus i m m u n i z a t i o n was u n k n o w n . Physical e x a m i n a t i o n revealed an average-sized m a n w h o had an odor of alcohol on his breath. His vital signs were a blood pressure of 160/100 m m Hg; pulse, 104; respirations, 16; and temperature, 36.8 C. The p a t i e n t was awake; a l e r t ; oriented to person, place, and time; and speaking coherently. He had no stridor or any evidence of airway obstruction. The trachea was midline. There was a superficial 6-cm laceration on the right side of his neck 2 c m below the m a n d i b l e that did n o t extend through the platysma. There was a 1-cm laceration on the back of the n e c k in the m i d l i n e at the level of C6. There was no cervical vertebral tenderness. There was no evidence of any n e c k swelling. Pupils were 4 cm, equal, and reactive to light. His extraocular m o v e m e n t s were n o r m a l and his discs were sharp. T h e lungs were clear, and the heart and a b d o m i n a l e x a m i n a t i o n s were normal. The neurological e x a m i n a t i o n was r e m a r k a b l e only for decreased sensation to light touch and p i n p r i c k on the volar tip of his right t h u m b . Cranial nerveg II-XII were intact. T h e p a t i e n t had 5/5 m o t o r strength in all upper and lower e x t r e m i t y m u s c l e groups. His reflexes were 2 + and s y m m e t r i c . Rectal tone was normal. The patient w a l k e d in w i t h a n o r m a l gait, and cerebellar function was intact. There were no other stab w o u n d s or other
98/662
Annals of Emergency Medicine
20:6 June 1991
EPIDURAL HEMATOMA Olshaker & Barish
FIGURE 1. Cervical-spine CT scan showing increased soft tissue density at C5-C6 consistent with a hematoma.
FIGURE 2. CT myelogram revealing a cervical epidural hematoma compressing the right lateral aspect of the thecal sac at the level of C5-C6. evidence of trauma. The patient was placed in a rigid cervical collar and placed on a backboard. Cervical-spine films showed no sign of fracture, foreign body, or ligamentous injury. After neurosurgical consultation, further diagnostic studies were performed. A right vertebral and carotid arteriogram was normal. Noncontrast head computed tomography (CT) was normal. A cervical-spine CT was remarkable for increased soft tissue density at C5C6 consistent with a hematoma (Figure 1). A C T myelogram revealed a cervical epidural h e m a t o m a compressing the right lateral aspect of the thecal sac at the level of C5-C6 without evidence of avulsion of nerve roots (Figure 2). The patient was admitted to the neurosurgical service and observed closely. His s y m p t o m s i m p r o v e d steadily over the next few days, and he showed no signs of cerebrospinal fluid leak or infection. He was discharged five days after admission. DISCUSSION The first case of spinal epidural hematoma was clinically diagnosed in 1969 by Jackson.1 Spinal epidural hematomas (SEH) are uncommon and, 20:6:June1991
unlike intracranial epidural hematomas, are more frequently spontaneous than those associated from trauma. 2-4 The clot is generally from disruption of the epidural venous plexus in response to t r a u m a or sudden increase of either transmitted intrathoracic or intra-abdominal pressure. Risk factors for both spontaneous and traumatic SEH are bleeding disorders, epidural vascular malformations, and arthritic disease of the vertebrae. Review of the literature reveals that post-traumatic SEHs have been secondary to falls, motor vehicle accidents, child abuse, physical assault with blunt objects, and missile injuries. 2 Our case appears to be the first report of SEH caused by a stab wound. This case is also unusual with regard to the minimal neurologic deficits the patient experienced. SEHs, particularly of the cervical spine, frequently follow a rapid course. The first symptom is usually focal pain in the individual spinal segment, which corresponds to the localization of the hemorrhage. This is usually followed by rapid and progressive motor and sensory deficits. 4-6 The standard method of diagnosis of this entity has been CT with myelography.7, s Magnetic resonance imaging is increasingly playing a greater role in the diagnosis of SEH. 9q2 Magnetic resonance imaging is capable of providing details of both intra- and extramedullary cord abnormalities without the administration of contrast. It is capable of detecting ligamentous injuries as well as areas of hemorrhage or edema that are not Annals of Emergency Medicine
readily diagnosed with other imaging techniques. The present use of magnetic resonance imaging is limited by its incompatibility with "the array of monitoring and ventilation equipm e n t that accompanies some patients. Further technological development to handle this equipment as well as increased availability will increase the role of magnetic resonance imaging. O n c e the d i a g n o s i s of SEH is reached, emergency decompressive therapy is usually necessary.~,3,13 Only with small, minimally symptomatic SEHs may spontaneous recovery be expected. Our patient had minimal symptoms and was managed s u c c e s s f u l l y by o b s e r v a t i o n alone. Any progression of symptoms would have required surgical intervention.
SUMMARY We present the case of a man with traumatic cervical spinal epidural hematoma from a stab wound. Spinal epidura] hematoma is not a common entity but should be considered in any individual presenting with any neurologic deficits corresponding to spinal cord involvement, either spontaneously or after trauma. Its recognition by emergency physicians is essential in leading to good outcome and neurologic recovery.
REFERENCES t. Jackson R: Case of spinal apolexy. Lancet 1869;2:5-6. 2. Foo D, Rossier AB: Post traumatic spinal epidural hematoma. Neurosurgery t982;lh25-32. 3. Garza-Mercado R: Traumatic extradural hematoma of the cervical spine. Neurosurgery 1989~24:4t0-414. 4. Matsumae M, Shimoda M, Shibuya N, et a]: Sponta~ neous cervical epidural h e m a t o m a . Surg Neuroi
663/99
EPIDURAL HEMATOMA Olshaker & Barish
1987~28:381-384.
mogr 1984;8:322-323.
aging. Ne~zxoradiology 1988;30:280.
5. Beatty RM, Wirstan KR: Spontaneous cervical epidural hematolna: A consideration of etiology. J Neuro surg 1984;61:143-146.
8. Zilkha A, Irwin GA, Fagelman D: Computed tomography of spinal epidural h e m a t o m a . AJNR 1983;4: 1073-1076.
11. Kulkarni ML, McArdle CB, Kopanicky D, et al: Acute spinal cord injury: MR imaging at 1.5T. Radiology 1987;64:837-843.
6. Markham JW, Lynge HL, Stahlman GEB: The syn drome of spontaneous spinal epidural hematoma. Report of three cases. J Neurosurg 1967;26:334-342.
9. Pan G~ Kulkarni M, MaeDougall DO, et al: Traumatic epidural hematoma of the cervical spine: Diagnosis with magnetic resonance imaging. J Neurosurg 1988; 68:798-801.
12. Tart RW, Drolshagen LF, Kerner C, et al: MRI imaging of recent spine trauma. [ Comput Assist Tomogr 1987;11:412-417.
7. Kaiser MC, Capesius P, Olanna F, et al: Computed tomography of acute spinal epidural hematoma associated with cervical root avulsion. J Comput Assist To-
100/664
10. Bernsen PLJA, Haan J, Vielvoye GJ, et al: Spinal epidural hematoma visualized by magnetic resonance im
Annals of Emergency Medicine
13. Foo D, Rossier AB: Preoperative neurological states in predicting surgical outcome of spinal epidural hema~ tomas. Surg Neurol 1981;15:389-401.
20:6 June 1991
A c u t e T r a u m a t i c Cervical Epidural H e m a t o m a From a Stab Wound Cervical spinal epidural hematoma is an infrequent entity that usually requires emergency decompressive therapy because of rapid neurologic dysfunction. We present the case of a 34-year-old man who presented to the emergency department with mirlimal symptomatology after a stab wound to the neck. A computed tomography myelogram of the cervical spine revealed a cervical spinal epidural hematoma. This case illustrates an unusual presentation as well as etiology of cervical spinal epidural hematoma. [Olshaker JS, Barish RA: Acute traumatic cervical epiduraI hematoma from a stab wound. Ann Emerg Med June 1991;20:662-664.] INTRODUCTION Spinal epidura] h e m a t o m a is an u n c o m m o n e n t i t y that u s u a l l y occurs from spontaneous causes, but is occasionally due to trauma. It is u s u a l l y associated w i t h rapid progression of neurologic deficits requiring surgical decompression. Its early diagnosis and t r e a t m e n t is essential for a good outcome. On review of the literature, this appears to be the first case report of a cervical spinal epidural h e m a t o m a from a stab wound. This case is also u n u s u a l in the p a u c i t y of signs and s y m p t o m s the patient experienced.
Jonathan S OIshaker, MD, FACEP Robert A Barish, MD, FACEP Baltimore, Maryland From the Division of Emergency Medicine, Department of Surgery, University of Maryland Medical System, Baltimore. Received for publication October 19, 1990. Accepted for publication January 3, 1991. Address for reprints: Jonathan S Olshaker, MD, FACER Division of Emergency Medicine, Department of Surgery, University of Maryland Medical System, 22 South Greene Street, Baltimore, Maryland 21201.
CASE REPORT A 34-year-old m a n presented to the e m e r g e n c y d e p a r t m e n t w i t h the history of being stabbed twice in the neck three hours earlier by a female acquaintance, He denied loss of consciousness, head trauma, or any other injuries. He i n i t i a l l y c o m p l a i n e d of only m i l d soreness at the site of the w o u n d on the back of his neck. On repeated questioning during the physical e x a m i n a t i o n he did a d m i t that his right t h u m b had felt n u m b since shortly after the assault. His medical h i s t o r y was r e m a r k a b l e only for an a d m i s s i o n two years earlier for esophageal varices. He was on no m e d i c a t i o n s and had no allergies. He a d m i t t e d to occasional alcohol use. His last tetanus i m m u n i z a t i o n was u n k n o w n . Physical e x a m i n a t i o n revealed an average-sized m a n w h o had an odor of alcohol on his breath. His vital signs were a blood pressure of 160/100 m m Hg; pulse, 104; respirations, 16; and temperature, 36.8 C. The p a t i e n t was awake; a l e r t ; oriented to person, place, and time; and speaking coherently. He had no stridor or any evidence of airway obstruction. The trachea was midline. There was a superficial 6-cm laceration on the right side of his neck 2 c m below the m a n d i b l e that did n o t extend through the platysma. There was a 1-cm laceration on the back of the n e c k in the m i d l i n e at the level of C6. There was no cervical vertebral tenderness. There was no evidence of any n e c k swelling. Pupils were 4 cm, equal, and reactive to light. His extraocular m o v e m e n t s were n o r m a l and his discs were sharp. T h e lungs were clear, and the heart and a b d o m i n a l e x a m i n a t i o n s were normal. The neurological e x a m i n a t i o n was r e m a r k a b l e only for decreased sensation to light touch and p i n p r i c k on the volar tip of his right t h u m b . Cranial nerveg II-XII were intact. T h e p a t i e n t had 5/5 m o t o r strength in all upper and lower e x t r e m i t y m u s c l e groups. His reflexes were 2 + and s y m m e t r i c . Rectal tone was normal. The patient w a l k e d in w i t h a n o r m a l gait, and cerebellar function was intact. There were no other stab w o u n d s or other
98/662
Annals of Emergency Medicine
20:6 June 1991
EPIDURAL HEMATOMA Olshaker & Barish
FIGURE 1. Cervical-spine CT scan showing increased soft tissue density at C5-C6 consistent with a hematoma.
FIGURE 2. CT myelogram revealing a cervical epidural hematoma compressing the right lateral aspect of the thecal sac at the level of C5-C6. evidence of trauma. The patient was placed in a rigid cervical collar and placed on a backboard. Cervical-spine films showed no sign of fracture, foreign body, or ligamentous injury. After neurosurgical consultation, further diagnostic studies were performed. A right vertebral and carotid arteriogram was normal. Noncontrast head computed tomography (CT) was normal. A cervical-spine CT was remarkable for increased soft tissue density at C5C6 consistent with a hematoma (Figure 1). A C T myelogram revealed a cervical epidural h e m a t o m a compressing the right lateral aspect of the thecal sac at the level of C5-C6 without evidence of avulsion of nerve roots (Figure 2). The patient was admitted to the neurosurgical service and observed closely. His s y m p t o m s i m p r o v e d steadily over the next few days, and he showed no signs of cerebrospinal fluid leak or infection. He was discharged five days after admission. DISCUSSION The first case of spinal epidural hematoma was clinically diagnosed in 1969 by Jackson.1 Spinal epidural hematomas (SEH) are uncommon and, 20:6:June1991
unlike intracranial epidural hematomas, are more frequently spontaneous than those associated from trauma. 2-4 The clot is generally from disruption of the epidural venous plexus in response to t r a u m a or sudden increase of either transmitted intrathoracic or intra-abdominal pressure. Risk factors for both spontaneous and traumatic SEH are bleeding disorders, epidural vascular malformations, and arthritic disease of the vertebrae. Review of the literature reveals that post-traumatic SEHs have been secondary to falls, motor vehicle accidents, child abuse, physical assault with blunt objects, and missile injuries. 2 Our case appears to be the first report of SEH caused by a stab wound. This case is also unusual with regard to the minimal neurologic deficits the patient experienced. SEHs, particularly of the cervical spine, frequently follow a rapid course. The first symptom is usually focal pain in the individual spinal segment, which corresponds to the localization of the hemorrhage. This is usually followed by rapid and progressive motor and sensory deficits. 4-6 The standard method of diagnosis of this entity has been CT with myelography.7, s Magnetic resonance imaging is increasingly playing a greater role in the diagnosis of SEH. 9q2 Magnetic resonance imaging is capable of providing details of both intra- and extramedullary cord abnormalities without the administration of contrast. It is capable of detecting ligamentous injuries as well as areas of hemorrhage or edema that are not Annals of Emergency Medicine
readily diagnosed with other imaging techniques. The present use of magnetic resonance imaging is limited by its incompatibility with "the array of monitoring and ventilation equipm e n t that accompanies some patients. Further technological development to handle this equipment as well as increased availability will increase the role of magnetic resonance imaging. O n c e the d i a g n o s i s of SEH is reached, emergency decompressive therapy is usually necessary.~,3,13 Only with small, minimally symptomatic SEHs may spontaneous recovery be expected. Our patient had minimal symptoms and was managed s u c c e s s f u l l y by o b s e r v a t i o n alone. Any progression of symptoms would have required surgical intervention.
SUMMARY We present the case of a man with traumatic cervical spinal epidural hematoma from a stab wound. Spinal epidura] hematoma is not a common entity but should be considered in any individual presenting with any neurologic deficits corresponding to spinal cord involvement, either spontaneously or after trauma. Its recognition by emergency physicians is essential in leading to good outcome and neurologic recovery.
REFERENCES t. Jackson R: Case of spinal apolexy. Lancet 1869;2:5-6. 2. Foo D, Rossier AB: Post traumatic spinal epidural hematoma. Neurosurgery t982;lh25-32. 3. Garza-Mercado R: Traumatic extradural hematoma of the cervical spine. Neurosurgery 1989~24:4t0-414. 4. Matsumae M, Shimoda M, Shibuya N, et a]: Sponta~ neous cervical epidural h e m a t o m a . Surg Neuroi
663/99
EPIDURAL HEMATOMA Olshaker & Barish
1987~28:381-384.
mogr 1984;8:322-323.
aging. Ne~zxoradiology 1988;30:280.
5. Beatty RM, Wirstan KR: Spontaneous cervical epidural hematolna: A consideration of etiology. J Neuro surg 1984;61:143-146.
8. Zilkha A, Irwin GA, Fagelman D: Computed tomography of spinal epidural h e m a t o m a . AJNR 1983;4: 1073-1076.
11. Kulkarni ML, McArdle CB, Kopanicky D, et al: Acute spinal cord injury: MR imaging at 1.5T. Radiology 1987;64:837-843.
6. Markham JW, Lynge HL, Stahlman GEB: The syn drome of spontaneous spinal epidural hematoma. Report of three cases. J Neurosurg 1967;26:334-342.
9. Pan G~ Kulkarni M, MaeDougall DO, et al: Traumatic epidural hematoma of the cervical spine: Diagnosis with magnetic resonance imaging. J Neurosurg 1988; 68:798-801.
12. Tart RW, Drolshagen LF, Kerner C, et al: MRI imaging of recent spine trauma. [ Comput Assist Tomogr 1987;11:412-417.
7. Kaiser MC, Capesius P, Olanna F, et al: Computed tomography of acute spinal epidural hematoma associated with cervical root avulsion. J Comput Assist To-
100/664
10. Bernsen PLJA, Haan J, Vielvoye GJ, et al: Spinal epidural hematoma visualized by magnetic resonance im
Annals of Emergency Medicine
13. Foo D, Rossier AB: Preoperative neurological states in predicting surgical outcome of spinal epidural hema~ tomas. Surg Neurol 1981;15:389-401.
20:6 June 1991
