Spinal epidural hematomas are rare and can result in severe morbidity if treatment is delayed and they are thus typically considered a surgical emergency. 

Clinical presentation

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

Pathology

Spinal epidural hematomas are most commonly spontaneous venous bleeds, often in the setting of coagulopathy or over-anticoagulation. They are anatomically located in the space between the theca and the periosteum - known as the extradural neural axis compartment.

Etiology

• 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

Location

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

Radiographic features

CT

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

MRI

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

• T1: isointense or hyperintense to spinal cord

• T2: heterogeneously hyperintense to spinal cord with hypointense foci

• SWI/T2*: blooming artifact

Differential diagnosis

• spinal epidural abscess

• spinal subdural hematoma

• other spinal epidural masses

Practical points

• assessment of spinal cord compression and spinal nerve roots should always be done.