Surgical Decompression in a 32-Year-Old Man with Chronic Onset of Thoracic Spontaneous Spinal Epidural Hematoma: A Case Report

Introduction

Spontaneous spinal epidural hematoma is defined as the presence of blood within the epidural space without any known traumatic or iatrogenic causes [1] (Figure 1). The estimated incidence is 0.1 per 100 000 individuals annually [2]. Spontaneous epidural hematoma of undetermined etiology is a rare neurological disorder, and spinal cord injury resulting from this condition has become a significant cause of long-term disability [3,4]. Spontaneous epidural hematoma typically presents with acute, severe pain at the site of hemorrhage, often radiating to the limbs. The condition progresses rapidly, with acute paraplegia commonly developing within a short time frame [5]. The prominent and severe clinical manifestations frequently lead to permanent neurological deficits, negatively impacting patients’ ability to perform daily activities, their level of social integration, and their overall quality of life [6]. Currently, MRI (magnetic resonance imaging) is the preferred diagnostic modality [7,8]. In symptomatic cases of spinal epidural hematoma, urgent surgical decompression of the spinal canal is typically performed as the treatment of choice [9].

In contrast to previously reported cases of thoracic spontaneous epidural hematoma, the onset in this case did not result in rapid deterioration leading to severe neurological deficits, but instead unfolded as a 2-month progressive course. This article reports a case of a 32-year-old man who recovered following surgical decompression of a chronically progressing epidural hematoma in the thoracic spinal segment.

Case Report

A 32-year-old Asian man was admitted with a history of chest and back pain, accompanied by bilateral lower-limb weakness, persisting for over 2 months. Prior to admission, he had undergone multiple unsuccessful conservative treatments at a local clinic. He was alert and oriented, with no significant medical history and no history of smoking or alcohol consumption. Physical examination revealed a positive straight-leg raise test result for both lower limbs, normal sensory function (Grade 5) in the right lower limb, muscle strength of 3/5 in the left lower limb, bilateral lower-limb numbness, reduced pain sensation in the feet, positive bilateral Babinski signs, and tenderness over the thoracolumbar spinous processes and paraspinal areas. Other reflexes were normal, and the femoral nerve stretch test was negative. Given the suspicion of a space-occupying lesion in the thoracic spinal canal, further imaging studies were recommended.

MRI of the thoracic spine revealed a mass located on the left posterior aspect of the spinal canal at the T1–2 level. The mass displayed a strip-like signal on T1-weighted imaging, and high signal intensity on both T2-weighted and T2 FLAIR sequences. The lesion measured approximately 3.0×1.2×0.5 cm, with well-defined borders, and it was compressing the adjacent spinal cord (Figure 2). Contrast-enhanced cervical spine imaging confirmed these findings (Figure 3). Thoracic spine radiographs showed no significant vertebral abnormalities (Figure 4), and abdominal and upper-abdominal CT (computed tomography) scans excluded other potential diagnoses, leading to a suspicion of a space-occupying lesion at the T1–2 vertebral level.

Due to the patient’s neurological dysfunction associated with spinal cord injury and localized signs, he underwent total laminectomy and decompression within 24 hours of admission. In the epidural space, dark red blood, clotted blood, thickened yellow ligaments, and adhesions were observed. Postoperative neurological function was normal, and follow-up MRI showed complete removal of the mass (Figure 5). The drainage tube was removed on the second postoperative day, and the patient recovered well, with complete resolution of thoracic back pain and significant improvement in lower-limb weakness. Follow-up evaluations at 2 weeks, 1 month, and 1 year showed no abnormalities, with complete resolution of the initial symptoms of thoracic back pain and lower limb weakness.

Discussion

Spontaneous spinal epidural hematoma is a rare condition that can lead to devastating consequences if not diagnosed and treated promptly. This report describes a rare case of chronic progressive spontaneous thoracic epidural hematoma, which was successfully managed through total laminectomy and spinal decompression.

Spontaneous spinal epidural hematoma was first described by Jackson in 1869, who referred to it as a special type of “blood hernia” [10]. These hematomas are most commonly found at the C6 and T12 vertebrae [11]. Similarly, most spontaneous epidural hematomas occur in the cervicothoracic region, often involving multiple spinal segments, with an average hematoma size spanning more than 6.3 vertebral segments [12]. Spontaneous epidural hematoma is characterized by high signal intensity on T2-weighted MRI images [13]. The condition typically progresses rapidly, and acute chest pain and paraplegia may be the initial manifestations of an acute epidural hematoma [14]. Prodromal headaches may be the only symptom preceding spinal or meningeal signs in cases of spontaneous epidural hematoma [15].

In this report of a chronic progressive thoracic spontaneous epidural hematoma, the patient initially presented with slowly progressing chest and back pain, along with bilateral lower-limb weakness. After more than 2 months of persistent symptoms and ineffective acupuncture treatment at a local clinic, the patient sought care at our hospital. MRI with T2-weighted imaging revealed a well-defined abnormal signal lesion measuring 3.0×1.2×0.5 cm, demonstrating high signal intensity. The lesion was initially suspected to be a schwannoma, which typically appear on MRI as well-demarcated, oval-shaped masses with a capsule and homogeneous enhancement [16]. Nerve root resection in schwannoma cases can reduce the risk of local recurrence, and the excised lesion should be confirmed by pathology [17].

Due to the patient’s neurological dysfunction and local signs suggestive of spinal cord injury, immediate surgical intervention was performed, consisting of 24-hour total laminectomy and spinal decompression. Intraoperatively, dark red hemorrhagic fluid, coagulated blood clots, thickened yellow ligaments, and adhesions were found in the epidural space. Correlating the imaging findings with intraoperative observations, the patient was diagnosed with a spontaneous thoracic epidural hematoma. On the second postoperative day, he reported complete resolution of chest and back pain, with significant improvement in bilateral lower-limb weakness. He was fully recovered at the time of discharge, and follow-up over the next year revealed no abnormalities.

A 33-year-old female patient with spontaneous spinal epidural hematoma reported by Shah presented with acute onset of pain around the hematoma site, followed by severe weakness in the upper and lower limbs, with MRI showing a heterogeneous accumulation in the spinal epidural space [18]. Similarly, a 17-year-old male patient with a thoracic epidural hematoma reported by Lannum initially presented with acute pain around the hematoma site, progressing to gradual weakness and numbness in the upper limbs, complete paraplegia, sensory loss, and persistent penile erection [19]. Compared to the chronic progression observed in the current case, both of these cases had acute-onset pain around the hematoma site, followed by weakness in all limbs and even paralysis. However, similar to the present case, in both reports MRI was the primary diagnostic tool, followed by decompressive laminectomy for surgical treatment. In contrast to the present case, which involved relatively mild symptoms prior to surgery and complete recovery postoperatively, the 33-year-old woman in Shah’s report had severe preoperative weakness in the upper and lower limbs, with notable functional improvement after surgery, although some motor strength was still lost. The 17-year-old male in Lannum’s report presented with paralysis preoperatively, with recovery of sensation and strength postoperatively; however, he required assistance for walking, experienced urinary retention necessitating self-catheterization, and had moderate constipation requiring medication. Unlike the 2 cases reported by Shah and Lannum, which involved acute onset and immediate medical intervention, the current case was evaluated after 2 months of pain, yet the postoperative recovery was significantly better, indicating that the treatment outcome of spontaneous epidural hematoma largely depends on the severity of preoperative neurological deficits. This conclusion is consistent with the findings of Wells and Bakker [20,21].

When a patient presents with sudden or gradually progressing chest/back or neck pain followed by weakness or even paralysis in the limbs, immediate MRI/CT evaluation should be performed. If a compressive hematoma is diagnosed, timely surgical evacuation is necessary. Early diagnosis, assessment, and prompt surgical evacuation of the hematoma, along with bleeding control, can result in favorable neurological outcomes, while delayed treatment can lead to permanent damage or paralysis [22,23]. Studies have shown that, compared to non-spontaneous cases, patients with thoracic spontaneous epidural hematoma tend to have a longer median time from symptom onset to surgery, a broader hematoma range, and poorer postoperative clinical outcomes [24]. Clinicians must remain vigilant to the potential risks of spinal epidural hematoma to avoid delaying optimal treatment.

Conclusions

We report a rare case of a slowly progressing thoracic spontaneous epidural hematoma. When patients present with chest/back or neck pain without obvious trauma or coagulation disorders, clinicians should consider the diagnosis of spontaneous spinal epidural hematoma. The degree of postoperative neurological recovery is influenced by the duration of surgical delay and the extent of preoperative neurological damage. Rapid recognition of symptoms and timely intervention can lead to significant neurological improvement and favorable outcomes in many patients with spontaneous spinal epidural hematoma.