Spinal epidural hematoma

Last revised by Dr Mohamed Saber on 25 Nov 2020

Spinal epidural hematomas (EDH) are a rare spinal pathology which can result in serious morbidity with delayed or non-treatment. They are typically considered a surgical emergency. 

The patient's symptoms and signs will depend on the location of the EDH, and degree of spinal cord / cauda equina compression, but invariably there will be a combination of severe pain and neurological deficit. See spinal cord injury and cauda equina syndrome for more information. 

Spinal EDH is most commonly spontaneous venous bleeds, often in the setting of coagulopathy or over-anticoagulation. They are anatomically located in what is known as the extradural neural axis compartment, located between the dura propria (visceral layer) and periosteum. 

  • spontaneous (most common 4)
    • especially in the context of a bleeding disorder or over-anticoagulation
  • trauma, e.g. vertebral fracture
  • iatrogenic, e.g. lumbar puncture, epidural anesthesia
  • spinal arteriovenous malformations or other vascular anomalies
  • spinal tumors
  • pregnancy

Spinal EDH can occur throughout the spine but is most common in the cervicothoracic region, usually posterior to the thecal sac over 2-4 vertebral levels 1,4.

  • non-contrast: hyperdense (50-70 HU) extradural mass 4

Signal characteristics will vary on the age of the blood. Signal characteristics of acute spinal EDH 1,2,5:

  • T1: isointense or hyperintense to spinal cord
  • T2: heterogeneously hyperintense to spinal cord with hypointense foci
  • T2*: blooming artifact

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Cases and figures

  • Case 1: T2
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  • Case 2: T1 C+ fat sat
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  • Case 3: non-contrast CT
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  • Case 4: T2
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  • Case 5
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  • Case 6: thoracic and lumbar spine
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