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Advances in Orthopedics
Volume 2011, Article ID 516382, 3 pages
HemiparesisCaused by CervicalSpontaneous
SpinalEpiduralHematoma: A Reportof 3 Cases
KinyaNakanishi,Naoki Nakano,TakuyaUchiyama, andAmami Kato
Department of Neurosurgery, Kinki University School of Medicine, 377-2 Onohigashi, Osakasayama-shi, Osaka 589-8511, Japan
Correspondence should be addressed to Kinya Nakanishi, firstname.lastname@example.org
Received 25 February 2011; Revised 6 June 2011; Accepted 8 June 2011
Academic Editor: John P. Kostuik
Copyright © 2011 Kinya Nakanishi et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old
woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral
epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural
hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI
scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved
after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with
left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The
condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe
irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest
that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical
symptoms of sudden neck pain and radicular pain with progression to hemiparesis.
Spontaneous spinal epidural hematoma (SSEH) is uncom-
of the clinical presentation of the condition using radio-
graphic imaging. Here, we report three cases of SSEH with
hemiparesis, which is uncommon compared to the classical
pain followed by paralysis.
2.1. Case 1. The patient was a 73-year-old woman who
with radiation into her left shoulder. Over the next day, she
developed left hemiparesis and was admitted to our hospital.
An examination showed left hemiparesis (left upper and
lower extremities; manual muscle testing (MMT) 1/5) with
numbness in the left upper and lower extremities, without
facial palsy, dysarthria, and aphasia. Deep-tendon reflexes
were hypoactive on the left side with a left Babinski reflex. A
head CT scan was normal, but a cervical MRI scan revealed
a left posterolateral epidural hematoma at the C3–C6 level
(Figure 1). 24 hours after onset, right hemilaminectomy
from C3 to C5 and evacuation of the epidural hematoma
were performed. One day after surgery, the patient improved
to MMT 3/5, after 2 weeks improved to MMT 4/5 in the left
upper and lower extremities, and at the 2-year followup, the
patient continued left hemiparesis (MMT 4/5).
2.2. Case 2. The patient was a 62-year-old man who experi-
enced sudden pain of the posterior cervical region and
numbness of the right lower extremity when he bent
backward to administer eye drops. Subsequently, paralysis
developed in the right upper and lower extremities, and he
visited the emergency room of our hospital with suspicion of
a cerebral stroke. An examination showed right hemiparesis
(right upper and lower extremities; MMT 2/5) with numb-
ness in the right upper and lower extremities and bladder
2 Advances in Orthopedics
a left posterolateral epidural hematoma at the C3-C6 level with
spinal cord compression.
and rectal disturbance, without facial palsy, dysarthria, and
aphasia. Deep-tendon reflexes were hyperactive in the lower
extremities with a right Babinski reflex. Head CT and MRI
were normal, but cervical MRI showed a right dominant
posterolateral spinal epidural hematoma at the C6-T1 level
(Figure 2). 6hours after onset, hemilaminectomy from C6
to T1 and evacuation of the epidural hematoma were
performed. One day after surgery, the patient improved
to MMT 5/5 in the right upper and lower extremities, at
followup of 2 years he had no right hemiparesis.
2.3. Case 3. A 60-year-old woman developed sudden pain of
the posterior cervical region during a conversation. The pain
aggravated gradually, and she developed left hemiparesis
approximately 20minutes after the onset of pain. Head
CT and MRI were normal, but cervical MRI showed a
spinal epidural hematoma limited to the left spinal dorsal
region at the C2–C4 level (Figure 3). An examination on
the first visit to our hospital did not indicate muscle
weakness or sensory disturbance. Deep-tendon reflexes of
the four extremities were increased mildly, and the Babinski
reflex was absent on both sides. In the clinical course, left
hemiparesis improved rapidly and conservative treatment
was selected. Cervical MRI performed 2 weeks after onset
showed complete disappearance of the epidural hematoma.
a right posterolateral dominant epidural hematoma at the C6-T1
level with spinal cord compression arrow.
Spinal epidural hematoma was first described by Jackson
 in 1869. The yearly incidence is now thought to be
approximately 0.1 per 100,000 people , and the condition
is no longer considered to be rare due to increased diagnosis
by MRI. As possible etiology factors, minor trauma, sneez-
ing, whooping cough, voiding, vomiting, lifting, pregnancy,
hypertension, atherosclerosis, anticoagulants, and bleeding
diathesis have been mentioned [3, 4]. Analysis of a large
series of SSEH that were reported in the international
medical literature suggested a correlation between SSEH
and coexistence of arterial hypertension . These factors
may cause secondary spinal epidural hematoma with a
clear cause (60%) or spontaneous spinal epidural hematoma
(SSEH) of unclear cause (40%) [3, 5, 6]. SSEH tends to be
more common in middle-aged or older patients, in males
compared to females . The majority of SSEH are situated
in the C5-Th2 area .
The mechanism of development of SSEH is unclear. It
has been suggested that venous pressure may increase in line
with an increase in abdominal and intrathoracic pressure,
since the spinal vein is of the primitive type with no venous
valve, and that this may easily cause hemorrhage [7, 8].
Alternatively, SSEH may develop due to a collapse of the free
epidural artery following hemorrhage at a level that causes
Advances in Orthopedics3 Download full-text
Figure 3: Initial sagittal (a) and axial (b) MR images showing a
left posterolateral epidural hematoma at the C2-C4level with spinal
spinal cord compression, with acute onset and progress of
symptoms . Many reports have also suggested that SSEH
may be triggered by actions that increase venous pressure,
such as cough, sneezing, and holding of heavy baggage ,
and venous hemorrhage has also been proposed as a cause.
Gradual progress from development of pain to hemiparesis
caused by venous hemorrhage occurred in the three cases
reported here. The majority of SSEH are situated posterior
or posterolaterallyin the spinal canal.The morphological
pattern of anterior internal vertebral venous plexus (IVVP)
in the human fetus and in aged human cadavers is identical.
In contrast to the situation in the aged human, the lower
thoracic and lumbar posterior IVVP in the fetus is very
small and lacks prominent transverse venous bridges. The
morphological differences seem to give a clue to the origin
of the SSEH; in SSEH, an age-related segmental distribution
of the hematomas has been observed, which might be related
to the morphological changes that occur within the posterior
IVVP during the process of aging [4, 10].
Development of SSEH is characterized by symptoms of
sudden cervical or back pain followed rapidly by motor
paralysis or anesthesia [7, 11]. SSEH with hemiparesis is
less common but has been reported previously. In addition
to back pain, Groen and Goffin  reported symptoms of
hemiparalysis in 193 cases (58%), paralysis/anesthesia in
123 cases (37%), nerve root symptoms in 15 cases (4%),
and unclear symptoms in 2 cases (1%) in a review of 333
cases of spinal epidural hematoma. Hemiparesis has also
been reported in 2 of 10 patients with SSEH described by
Kimiwada et al. , in 6 of 35 patients in Liao et al. ,
and in 2 of 4 patients in Lonjon et al. . Collectively, these
reports show that hemiparesis is not uncommon in SSEH
patients. Our cases suggest that acute cervical spinal epidural
hematoma should be considered as a differential diagnosis in
patients presenting with clinical symptoms of sudden neck
pain and radicular pain with progression to hemiparesis.
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