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.

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.

• 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

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

• 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)

• Cervical SEH
• Thoracic Spinal Epidural Hematoma
• Lumbar SEH
• Sacral SEH
• Multilevel SEH (extends across >1 region)

• 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

• Stable SEH: Neurological symptoms non-progressive or improving
• Progressive SEH: Worsening neurological deficits
• Relapsing/Rebleeding SEH: Rare; typically in coagulopathy or vascular lesion

• Focal (<2 vertebral levels)
• Extensive (≥2 vertebral levels)
• Circumferential vs. Unilateral/Dorsal/Ventral hematomas

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

• 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)

• 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

• 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

• 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

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

• 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