Epidural hematoma (spinal)
Background
- Presentation and initial management are similar; difference is level of neuro deficit
Etiology
- Epidural abscess
- Malignancy
- Massive mid-line disk herniation
- Spinal canal hemorrhage
Clinical Features
Epidural compression syndromes table[1]
| Syndrome | Spinal cord compression | Conus medullaris syndrome | Cauda equina syndrome |
| Location of lesion | Lesions at vertebral level L2 | ||
| Spontaneous pain | Unusual and not severe; bilateral and symmetrical in perineum or thighs | Often very prominent and severe, asymmetrical, radicular | |
| Motor findings | Deficits usually affect both legs but are often asymmetric | Not severe, symmetrical; rarely twitches | May be severe, asymmetrical, fibrillary twitches of paralyzed muscles are common |
| Sensory findings | Weakness in lower extremities, paresthesias/sensory deficits, gait difficulty | Saddle distribution, bilateral, symmetrical, disassociated sensory loss (impaired pain and temperature with sparing of tactile) | Saddle distribution (75% pts), may be asymmetrical, no dissociation of sensory loss |
| Reflex changes | Achilles reflex may be absent | Patellar and Achilles reflexes may be absent | |
| Sphincter disturbance | Bladder and rectal sphincter paralysis usually reflect involvement of S3-S5 nerve roots | Early and marked (both urinary and fecal) | Late and less severe (60-80% pts) |
| Male sexual function | Impaired early | Impairment less severe | |
| Onset | Sudden and bilateral | Gradual and unilateral | |
| Other | Urinary retention with or without overflow incontinence (Sn 90%, Sp 95%) |
Differential Diagnosis
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Spinal fracture
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Renal disease
- Kidney stone
- Pyelonephritis
- Nephrolithiasis
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- PID
- Other
Spinal Cord Syndromes
Evaluation
- Emergent MRI
- If considering compression due to neoplasm obtain scan of entire spine
- Consider Bladder scan/ultrasound for bladder volume (post-void residual)
Management
General Epidural Compression Syndrome Management
- Dexamethasone: at least 16 mg IV as soon as possible after assessment[2]
- Note: dexamethasone can be used to reduce compressive edema from epidural metastases, but is more likely to worsen an infection from spinal epidural abscess.
- Consult spine service
- Consider foley for bladder decompression
See Also
- Epidural hemorrhage (intracranial)
References
- Bradley WG. Neurology in Clinical Practice: Principles of diagnosis and management. P363
- Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compression. Full Guideline. November 2008. Developed for NICE by the National Collaborating Centre for Cancer. ©2008 National Collaborating Centre for Cancer
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