Epidemiology
Acute spinal subdural hematoma (SSDH) is a rare spinal vascular disorder causing compression of the spinal cord or cauda equina [3]. In a review of 151 patients with non-traumatic spontaneous acute sSDH, 46% of patients either treated with anticoagulation therapy or harboured a coagulopathy attributable to a hematologic disorder [2]. In our case, patient was on oral anticoagulant for previous aortic prosthesis.
In a separate review of 106 cases of non-traumatic acute sSDH, a large proportion of the cases were associated with either bleeding disorders or purely iatrogenic causes, representing 54% and 14% of the cases, respectively [4]. In our present case, had undergone surgery for appendicitis under spinal anaesthesia 2 days before her admission in our neurosurgery department.
Clinical: A typical clinical presentation is sudden onset of spinal or radicular pain, and myelopathy such as paraplegia or sensory level [1]. Our patient had spinal cord compression Grade IV of Mc Cormick classification with flaccid paraplegia with grade 1/5 strength in his bilateral upper extremities and grade 1/5 strength throughout his bilateral lower extremities.
He noted umbilical sensitive level disorders.
Diagnosis assessment
MRI is considered the gold standard in the evaluation of sSDHs as it is capable of visualizing spinal hematomas as well as other spinal cord pathologies [1]. However, Braun et al. suggest performing spinal angiography when clinical suspicion of vascular malformation exists based on MRI findings [5]. We performed MRI in our case to assess of the diagnosis.
Management and follow up
The exact mechanism of spontaneous resolution of symptom is unclear. Several factors including small volume of hematoma prompt cease of active bleeding, flexibility of spinal cord, and appropriate width of spinal canal may influence on the recovery of the symptom [3].
Three treatment options exist in the management of sSDH: surgical evacuation, conservative medical management, and percutaneous drainage. Early symptoms without significant neurological deficits might considered for conservative management [6]. If only mild deficits are present, conservative management is reasonable. However, in the face of clinical deterioration or severe motor/sensory deficits, surgical evacuation is advised [7]. Percutaneous drainage might considered in cases where the hematoma is located dorsally and there is the absence of coagulopathy [8]. In our case, taking into account the signs of spinal cord compression Mc Cormick Grade IV, and the extent of the compressive hematoma, we retained the indication to operate the patient urgently. We perform laminectomy, durotomy to explore intradural and evacuated hematoma with gentle suction.
The mortality rates in patients with spontaneous non-traumatic sSDH have decreased in recent years and currently reported to be 1.3%. However, the associated morbidity, including serious neurologic deficits, is substantially higher and reported to be 28% [2]. Pereira et al. examined factors that predict outcome in patients with spontaneous no traumatic sSDH. Neurologic status at presentation was the strongest predictor of good outcomes; only 34% of patients with preexisting neurologic deficits had favourable outcomes compared to 83% of patients devoid of neurologic deficits at initial presentation [2]. In our case, patient had an immediate recovery of sensitivity and an onset of motor recovery from 1/5 to 2/5 follow up at on year with physiotherapy marked by recovery of motor deficit on upper to 4/5 and the lower extremities 4/5, he walk with walker help.
