Spontaneous Epidural Hematoma

An 8-year-old boy presented to the emergency department (ED) with a several day history of back pain and a 1-day history of bilateral arm pain. He rated his pain as being 10 of 10. He also complained of generalized weakness of the arms and legs, and he had difficulty with ambulation.

There was no history of trauma. He had no history of fevers, but he did have a mildly elevated temperature (38.0°C) in the ED at presentation.

On physical examination, the patient was in significant distress secondary to pain. He kept his neck in a flexed position. He had some tenderness to pain over the midline lower neck and upper back. He had no signs of trauma or deformity to the back, neck, or extremities. Generalized weakness was noted in the upper and lower extremities, with 4/5 strength at the biceps, triceps, grip, hip flexors, and dorsiflexion/plantar flexion. He had no tenderness to palpation anywhere in his extremities.

Magnetic resonance imaging revealed an epidural fluid collection extending from the third cervical vertebra to the third thoracic vertebra, suggesting the presence of an epidural hematoma or epidural abscess. The lack of significant fever or elevation of inflammatory markers made a hematoma more likely; nevertheless, there was no history of trauma.

The patient was taken to the operating room, where a cervical laminotomy with laminoplasty was performed. A large hematoma was evacuated. He required 2 more surgeries to evacuate reaccumulations of blood in the epidural space.

All evaluations for bleeding disorders or vascular anomalies of the epidural space have been negative to date. He has made a near-full recovery, although he still requires extensive physical therapy and occupational therapy.

Spinal epidural hematomas are a rare clinical event in children. Only 33 cases had been reported in the literature as of 2006.¹ Whereas epidural hematomas often follow major trauma in adults, the majority in children are spontaneous.² However, minor trauma (eg, minor falls, minor automobile accidents, weight-lifting) often has been associated with epidural hematomas in children.

The presenting symptoms typically are pain, irritability (in preverbal children), torticollis, sensorimotor deficits, and Brown-Séquard syndrome.

Rapid decompression of the spinal cord is essential to the outcome of children with epidural hematomas. With early diagnosis and intervention, the outcome is guardedly favorable.³ In a 1993 Japanese review,⁴ nearly two-thirds of patients achieved a return to normal function, and one-fourth returned to near normal function.

References:

1. Fountas KN, Kapsalaki EZ, Robinson JS. Cervical epidural hematoma in children: a rare clinical entity. Case report and review of the literature. Neurosurg Focus. 2006;20(2):E6.

2. Patel H, Boaz JC, Phillips JP, Garg BP. Spontaneous spinal epidural hematoma in children.
Pediatr Neurol. 1998;19(4):302-307.

3. Pecha MD, Able AC, Barber DB, Willingham AC. Outcome after spontaneous spinal epidural hematoma in children: case report and review of the literature. Arch Phys Med Rehabil. 1998; 79(4):460-463.

4. Iguchi T, Ito Y, Asai M, Ito J, Okada N, Murakami M. A case of spontaneous spinal epidural hematoma [in Japanese]. No To Hattatsu. 1993; 25(3):267-270.