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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 35-38

Delayed Epidural Hematoma Following Cervical Laminoplasty


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission02-Oct-2021
Date of Acceptance04-Oct-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Ravi Sreenivasan
Central Institute of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joss.joss_5_21

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  Abstract 


Postoperative spinal epidural hematoma following posterior cervical spinal surgery is a well-known complication. We report a patient who developed epidural hematoma following C4-D1 laminoplasty on the 10th postoperative day and developed worsening quadriparesis (after significant improvement in the postoperative period), and patient had no coagulation or bleeding disorders. The patient was managed by emergent evacuation of hematoma and recovered well. Our case highlights the fact that a postoperative epidural hematoma can occur anytime following posterior spinal surgery even in patients without any predisposing factors. To the best of our knowledge, only three such cases have been reported in the literature previously and two out of the three cases were on anticoagulants.

Keywords: Cervical spine, complications, epidural hematoma, laminoplasty


How to cite this article:
Sreenivasan R, Mohite A, Garg K, Borkar SA, Kale SS. Delayed Epidural Hematoma Following Cervical Laminoplasty. J Spinal Surg 2021;8:35-8

How to cite this URL:
Sreenivasan R, Mohite A, Garg K, Borkar SA, Kale SS. Delayed Epidural Hematoma Following Cervical Laminoplasty. J Spinal Surg [serial online] 2021 [cited 2022 Jan 21];8:35-8. Available from: http://www.jossworld.org/text.asp?2021/8/4/35/333623


  Introduction Top


Postoperative spinal epidural hematoma following posterior spinal surgery is a well-known complication, rare as it may be.[1],[2],[3],[4] It can have sudden and catastrophic neurological effects, including sensory, motor, bowel, and bladder deficits, even if the immediate postoperative period was uneventful. The reported incidence of postoperative spinal epidural hematomas is between 0.1% and 0.2%.[1],[2],[3] An urgent evacuation and decompression are mandatory if the patient is symptomatic to maximize the chances of neurological recovery.[1],[3] Most of these hematomas usually form within 24 h of surgery but can develop within 2–3 days also.[1],[3],[4],[5] Delayed hematoma formation is of extremely rare occurrence. We report a patient who developed epidural hematoma following C4-D1 laminoplasty on the 10th postoperative day and developed worsening quadriparesis, and patient had no coagulation or bleeding disorders.


  Case Report Top


History and examination

A 38-year-old man presented to our outdoor department with a gradually worsening ability to walk steadily even with the assistance of 1-month duration. He also complained of tingling sensation and numbness in both hands and feet. He also had bladder symptoms in the form of urge incontinence. The patient had no comorbidities (hypertension, diabetes mellitus, coagulopathies, and allergies). Neurological examination was suggestive of spastic myelopathy with spasticity in all four limbs. Motor power was grade 4/5 (Medical Research Council grade). Bilateral ankle and knee reflexes were exaggerated.

Investigations

Radiographs (dynamic lateral views) revealed decreased range of motion and loss of lordosis of the cervical spine [Figure 1]. CT scan of the cervical spine showed an ossified posterior longitudinal ligament (OPLL) extending from C4 to D1 with significant canal compromise [Figure 2]. MRI showed significant cord compression with no cord signal change [Figure 3]. The patient also had concomitant dorsal canal stenosis at D9/D10 due to ligamentum flavum and facet hypertrophy [Figure 4].
Figure 1: Radiographs (extension and flexion lateral views) showing a decreased range of motion and loss of cervical lordosis

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Figure 2: (a) Sagittal section CT scan showing ossified posterior longitudinal ligament spanning C4C5C6C7D1 (b) Axial section CT scan showing canal compromise due to OPLL in C4C5C6C7

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Figure 3: T2W Sagittal section MRI scan of the cervical spine showing OPLL as dark hypointense shadow compressing the cord from the anterior aspect. The cord does not show any signal intensity changes

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Figure 4: T2W Sagittal section MRI scan of whole spine showing OPLL in the cervical spine as well as dorsal canal stenosis due to hypertrophied ligamentum flavum at D6 and D9–D11 levels

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Surgical procedure

The patient was explained about the pathology and treatment options. He underwent an open door type C4-D1 laminoplasty [Figure 5]. The laminoplasty was secured with a miniplate and screws placed in the laminae and lateral masses of C4, C5, C6, C7, and D1 on the right side. The surgical time was 185 min with an estimated blood loss of 150 ml. The surgery was uneventful. Hemostasis was thorough, and the closure was watertight. There was no postoperative soakage of the dressing. He received non steroidal anti-inflammatory drugs (NSAIDs) for pain.
Figure 5: Postoperative radiographs anteroposterior and lateral views showing mini plates in situ securing an open-door laminoplasty from C4-D

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Postoperative course and re-exploration

The patient reported an improvement in symptoms with a decrease in the tingling sensations and numbness in all four limbs. Objectively, the spasticity also decreased and the patient gradually gained 4+/5 power in all four limbs for the next 2–3 days. He was ambulating by the 4th postoperative day and the sutures were removed on the 9th postoperative day. The next morning after a bout of cough, the patient noticed a swelling in the lower part of his neck that rapidly increased in size and became tense. There was mild blood discharge from one of the suture holes [Figure 6]a. Power in all four limbs deteriorated from 4/5 to 1/5 for 2 h. A diagnosis of epidural hematoma was made presumptively, and the patient was wheeled in for an emergency exploration of the wound. The patient was operated on within 4 h of the onset of symptoms. Intraoperatively, epidural hematoma (approximately 150 mL in volume) was found along with clots in the intermuscular plane [Figure 6]b. There was no split in the muscles and no dehiscence of any of the previously sutured tissue layers. The laminoplasty was secure, and there was no bony compression over the spinal cord. There were no active bleeders. Meticulous hemostasis was achieved [Figure 6]c. The wound was sutured in layers over a drain [Figure 6]d. The collected hematoma was sent for culture/Gram stain/histopathological examination which revealed no organism or specific tissue pathology. Complete coagulation profile, platelet function tests [Figure 7], and liver function tests were ordered and were found to be normal. The patient showed immediate neurological improvement and continued to improve gradually after the evacuation of the hematoma. The postoperative period was uneventful. At discharge, the patient was ambulatory and had 4/5 power in all four limbs.
Figure 6: (a) Photograph showing oozing of blood from proximal aspect of the suture line. (b) Intraoperative photograph showing hematoma in a subfascial plane. (c) Intraoperative photograph showing a secure and stable laminoplasty after complete hemostasis. No evidence of any infection was seen (d) Intraoperative photograph showing final wound closure over the suction drain in situ

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Figure 7: Photograph showing coagulation profile and platelet aggregation profile report of the patient

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  Discussion Top


Our case highlights the fact that a postoperative epidural hematoma can occur anytime following posterior spinal surgery. All the possible hematological causes of hematoma were ruled out after an extensive workup. A seemingly trivial event like a bout of cough can lead to stress on the wound and the formation of a hematoma in healthy young adults even 10 days after surgery after wound healing and suture removal. Spanier and Stambough[6] reported a delayed hematoma on the 16th postoperative day in a case of lumbar spinal surgery who had been initiated on heparin since the 12th postoperative day for treating postoperative deep vein thrombosis. Zhou et al.[7] reported a delayed hematoma in a cervical laminoplasty on the 9th postoperative day in a 78-year-old man who was self-medicating with aspirin without the treating physician's knowledge. Neo et al.[8] reported a case of delayed hematoma following a cervical laminoplasty on the 9th postoperative day due to inadvertent straining for defecation. There were no predisposing factors or bleeding disorders in their patient, like in our case.

Uribe et al.[9] reported a series of seven cases of spinal epidural hematomas with an average time of presentation at 5.3 days. They suggested that severe pain radiating to bilateral limbs in the postoperative period heralds an impending neurological deficit due to a hematoma. However, in our case, the patient was showing gradual improvement and had not complained of any disproportionate pain in the immediate postoperative period. Zhou et al.[7] suggested that C5 palsy is an indicator of an epidural compression postsurgery. In our case, there was no explicit C5 palsy, although the overall power post laminoplasty was 4/5.

Kou et al.[2] identified multilevel procedures and preoperative coagulopathy as risk factors for delayed epidural hematomas in 12 cases of lumbar spine surgery. Their reported incidence was 0.1%. Awad et al. reported a 0.2% incidence in 14,932 spinal surgeries and suggested age >60, Rh + blood type, use of NSAIDS, multilevel >5 segment surgery, Hb <10 g/dL, blood loss >1000 mL, and INR >2.0 in first 48 h as risk factors for spinal epidural hematomas. Our patient had an O + blood group and had undergone a multilevel procedure as well.

Quadriplegia as an effect of spinal epidural hematoma is uncommon. Numerous factors have been anecdotally implicated for spinal epidural bleeds including hypertension, anticoagulant therapy, straining, sneezing, coughing, lifting heavy weights, etc.; however, the pathogenesis and the etiology remains unknown in most cases. The improvement of symptoms correlates with the rapidity of evacuation and hemostasis in all cases that have been reported, and our case is no different. Lawton et al.[3] suggested that the neurological outcomes are far worse when the exploration surgery is delayed over 12 h. Preoperative neurological status and timing of surgery correlate well with the neurological outcome in the treatment of a spinal epidural hematoma.[10],[11]


  Conclusion Top


Patients need to be monitored carefully after surgery and should be followed up for 4–6 weeks at the least. They should be advised to refrain from any strenuous activity for that period. Healing of the skin and motor improvement postsurgery should not give a false sense of confidence as to everything being alright. Any hint of motor paresis or disproportionate pain should necessitate urgent investigations followed by emergency surgery to achieve good neural outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br 2005;87:1248-52.  Back to cited text no. 1
    
2.
Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine (Phila Pa 1976) 2002;27:1670-3.  Back to cited text no. 2
    
3.
Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: Relationship between surgical timing and neurological outcome. J Neurosurg 1995;83:1-7.  Back to cited text no. 3
    
4.
Yonenobu K, Hosono N, Iwasaki M, Asano M, Ono K. Neurologic complications of surgery for cervical compression myelopathy. Spine (Phila Pa 1976) 1991;16:1277-82.  Back to cited text no. 4
    
5.
Sokolowski MJ, Dolan M, Aminian A, Haak MH, Schafer MF. Delayed epidural hematoma after spinal surgery: A report of 4 cases. J Spinal Disord Tech 2006;19:603-6.  Back to cited text no. 5
    
6.
Spanier DE, Stambough JL. Delayed postoperative epidural hematoma formation after heparinization in lumbar spinal surgery. J Spinal Disord 2000;13:46-9.  Back to cited text no. 6
    
7.
Zhou FF, Zhang L, Zhao MW, Yu M, Sun Y. A case of delayed cervical epidural hematoma with C5 nerve root palsy after posterior cervical laminoplasty. Beijing Da Xue Xue Bao Yi Xue Ban 2007;39:443-4.  Back to cited text no. 7
    
8.
Neo M, Sakamoto T, Fujibayashi S, Nakamura T. Delayed postoperative spinal epidural hematoma causing tetraplegia. Case report. J Neurosurg Spine 2006;5:251-3.  Back to cited text no. 8
    
9.
Uribe J, Moza K, Jimenez O, Green B, Levi AD. Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-9.  Back to cited text no. 9
    
10.
Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: A study of the factors determining postoperative outcome. Neurosurgery 1996;39:494-508.  Back to cited text no. 10
    
11.
Liao CC, Lee ST, Hsu WC, Chen LR, Lui TN, Lee SC. Experience in the surgical management of spontaneous spinal epidural hematoma. J Neurosurg 2004;100:38-45.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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