Spinal Epidural Hematoma (SEH) [Neurosurgery Wiki]

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====== Spinal Epidural Hematoma (SEH) ======

A **Spinal [[Epidural Hematoma]] (SEH)** is a rare but potentially devastating condition characterized by bleeding into the **epidural space** of the spinal canal, which may compress the spinal cord or cauda equina and cause neurological deficits.

===== 🧠 Definition =====
A **SEH** is the accumulation of blood between the **dura mater** and the **vertebral periosteum**, which can lead to spinal cord or nerve root compression.

===== 📊 Epidemiology =====
  * Incidence: ~0.1 per 100,000 per year
  * Slight **male predominance**
  * Can occur at any age; more common in **middle-aged to elderly** adults
  * Most common locations: **cervical and thoracic** spine

===== 📂 Classification of Spinal Epidural Hematoma (SEH) =====

SEH can be classified based on **etiology**, **location**, **clinical evolution**, and **imaging features**:

==== 📌 By Etiology ====
  * **Spontaneous**:
    * Idiopathic
    * Associated with anticoagulation, coagulopathies, vascular malformations
  * **Traumatic**:
    * Spinal fractures
    * Sports injuries
  * **Iatrogenic**:
    * Post-lumbar puncture
    * Epidural catheterization or anesthesia
  * **Secondary to pathology**:
    * Tumors (vascular-rich neoplasms)
    * Infections (rare)

==== 📌 By Location ====
  * **Cervical SEH**
  * **[[Thoracic Spinal Epidural Hematoma]]**
  * **Lumbar SEH**
  * **Sacral SEH**
  * **Multilevel SEH** (extends across >1 region)

==== 📌 By Time of Evolution (Radiological Ageing on MRI) ====
  * **Hyperacute** (<24 h): Iso-/hyperintense on T2, iso-/hypointense on T1
  * **Acute** (1–3 days): Variable T1/T2 signals, possible cord compression
  * **Subacute** (3–7 days): Hyperintense on both T1 and T2
  * **Chronic** (>7 days): Capsule formation, heterogeneous signal, hemosiderin

==== 📌 By Clinical Evolution ====
  * **Stable SEH**: Neurological symptoms non-progressive or improving
  * **Progressive SEH**: Worsening neurological deficits
  * **Relapsing/Rebleeding SEH**: Rare; typically in coagulopathy or vascular lesion

==== 📌 By Extension on MRI ====
  * **Focal** (<2 vertebral levels)
  * **Extensive** (≥2 vertebral levels)
  * **Circumferential** vs. **Unilateral/Dorsal/Ventral** hematomas

==== 🧠 Clinical Utility ====
  * Guides urgency of treatment (e.g. progressive vs. stable)
  * Helps in choosing between surgical vs. conservative management
  * Useful for prognosis and monitoring recurrence risk


===== ⚠️ Etiology / Risk Factors =====
  * **Spontaneous** (idiopathic in 40–60% of cases)
  * **Anticoagulant therapy** (warfarin, DOACs)
  * **Trauma** (including minor)
  * **Iatrogenic** (epidural catheter, spinal tap)
  * **Coagulopathies**
  * **Vascular malformations**
  * **Neoplasms** or **infection** (rare)

===== 🔍 Clinical Presentation =====
  * **Acute severe back or neck pain**
  * Rapidly progressive **neurological symptoms**:
    * Weakness or paralysis
    * Sensory level
    * Bowel/bladder dysfunction
  * May mimic stroke, cauda equina syndrome, or transverse myelitis

===== 🧪 Diagnosis =====
  * **MRI spine with gadolinium**: gold standard
    * Hyperacute (<24h): isointense on T1, hyperintense on T2
    * Subacute: becomes hyperintense on T1 and T2
  * **CT myelogram**: alternative if MRI unavailable
  * **Coagulation profile**, CBC

===== ⚒️ Management =====
  * **Emergency decompressive surgery** (laminectomy or hemilaminectomy)
    * Especially if progressive or severe deficits
  * **Conservative management**:
    * Considered only if mild and improving symptoms
  * **Correct underlying coagulopathy**
  * **Steroid use**: controversial

===== 📈 Prognosis =====
  * Strongly depends on:
    * **Time to surgery** (ideally <12 hours)
    * **Severity of preoperative neurological impairment**
  * Early diagnosis and treatment → favorable outcomes

===== 📚 Notes =====
  * Must be considered in differential diagnosis of acute spinal cord compression
  * Prompt MRI and surgical referral are crucial
  * Anticoagulated patients with new back pain require urgent evaluation