Spinal subdural hematoma [Neurosurgery Wiki]

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====== Spinal subdural hematoma ======

===== Epidemiology =====

Spinal [[subdural hematoma]]s are a rare entity, much more so than [[spinal epidural hematoma]]s. In a meta-analysis of over 600 spinal hematomas, only 4% were subdural 
((Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with 
meta-analysis of 613 patients. Neurosurg Rev. 2003 Jan;26(1):1-49. Epub 2002 Sep 
24. Review. PubMed PMID: 12520314.
)).

===== Classification =====

[[Spontaneous spinal subdural hematoma]]

[[Traumatic spinal subdural hematoma]]

[[Spinal chronic subdural hematoma]].

===== Etiology =====

Factors that predispose to subdural hematoma include:

[[Coagulopathy]]
    
[[Anticoagulant]] therapy:

Till 2015, only three published cases report the incidence of [[rivaroxaban]]-induced nontraumatic spinal subdural hematoma (SSDH)
((Zaarour M, Hassan S, Thumallapally N, Dai Q. Rivaroxaban-Induced Nontraumatic 
Spinal Subdural Hematoma: An Uncommon Yet Life-Threatening Complication. Case Rep
Hematol. 2015;2015:275380. doi: 10.1155/2015/275380. Epub 2015 Oct 12. PubMed
PMID: 26543654; PubMed Central PMCID: PMC4620391.
))
    
[[Spinal vascular malformation]]s
    
Percutaneous spinal [[intervention]]
    
Back surgery 
    
Trauma uncommon cause
    
A combination of any of the above


===== Clinical features =====

Symptoms are those of spinal cord compression or cauda equina syndrome, often presenting initially as back pain and/or radicular pain. Symptoms tend to develop more rapidly with subdural hematomas
((Pierce JL, Donahue JH, Nacey NC, Quirk CR, Perry MT, Faulconer N, Falkowski
GA, Maldonado MD, Shaeffer CA, Shen FH. Spinal Hematomas: What a Radiologist
Needs to Know. Radiographics. 2018 Sep-Oct;38(5):1516-1535. doi:
10.1148/rg.2018180099. Review. PubMed PMID: 30207937.)).


===== Diagnosis =====

[[Spinal subdural hematoma diagnosis]].

===== Differential diagnosis =====

It is important to distinguish between [[subdural hematoma]]s and other entities which can occupy the spinal subdural space:

Spinal [[subdural empyema]]: rare

Different history and clinical picture, including fever local extension or haematogenous spread, or iatrogenic
behaves differently on MRI
    
Spinal subdural hygroma: CSF collection
Appears as clumping of nerve roots in shape of inverted Mercedes-Benz sign
        
Injury to dura mater may be directly detected

Large hygroma can show MRI signs of craniospinal hypotension:

dural venous distension
            
pachymeningeal enhancement
            
decreased pontomesencephalic angle
    
Epidural lipomatosis: fat-sat sequences will help differentiation between early subacute SSDH and lipomatosis
    
Intradural-extramedullary mass: meningiomas and nerve sheath tumors (both common) enhance avidly, while arachnoid cysts follow CSF signal on all sequences
    
Arachnoiditis: nerve root clumping surrounded entirely by CSF (i.e. not the inverted Mercedes-Benz appearance)


===== Treatment =====

Conservative treatment with watchful waiting (i.e. follow-up with serial MRIs) is acceptable for small collections. In case of significant neurologic defects, laminectomy with clot evacuation is done.

===== Outcome =====
Although prompt diagnosis and emergent surgical intervention are important in acute spinal subdural hematoma (SSDH), some cases with spontaneous remission of symptom and hematoma without surgery have been reported. 

Cervical and thoracic SSDH are associated with a worse outcome than lumbar SSDH, as is coexisting spinal subarachnoid hematoma (SSAH).

===== Case reports =====
Farzan A, Pourbakhtyaran E, Moosavian T, Moosavian H. [[Spinal Subdural
Hematoma]]s in a Normal Child without Trauma History: A Case Report. Iran J Child
Neurol. 2019 Summer;13(3):121-124. PubMed PMID: 31327977; PubMed Central PMCID:
PMC6586447.