25 Spinal Emergencies

Mohammed Eleraky and Frank D. Vrionis

I. Key Points

– Prompt and accurate diagnosis of spinal emergencies is critical because return of function is highly dependent on early intervention.

– Magnetic resonance imaging (MRI) is often the imaging modality of choice in diagnosing spinal hematomas, acute herniated nucleus pulposus, and spinal epidural abscesses.

– Trauma and tumors may also present as “spinal emergencies” and are discussed elsewhere.

II. Spinal Hematomas

– Background

• As in the cranium, these include subdural, epidural, and subarachnoid hematomas.

• In up to one-third of cases, no etiologic factor can be identified.

• Anticoagulant therapy and vascular malformations represent the second and third most common causes.

• Spinal hematomas are typically localized dorsally to the spinal cord at the cervicothoracic and thoracolumbar regions.^1,2

• Subarachnoid hematomas can extend along the entire length of the subarachnoid space.

• Intramedullary hemorrhages, caused by cavernomas or arteriovenous malformations (AVMs), typically produce devastating neurologic symptoms but are often not managed with emergent surgical decompression.

– Signs, symptoms, and physical exam

• Epidural and subdural spinal hematomas present with intense, knife-like pain at the location of the hemorrhage (“coup de poignard”).

• This may be followed by a pain-free interval of minutes to days.

• Subarachnoid hematoma can be associated with meningitis-like symptoms, disturbances of consciousness, and epileptic seizures (often misdiagnosed as cerebral hemorrhage based on these symptoms).

• Symptoms depend on the location and extent of hemorrhage and may include motor weakness, sensory and reflex deficits, and acute bowel/bladder dysfunction.¹

• The imaging modality of choice is MRI with or without gadolinium (Fig. 25.1).

• The appearance of hematomas in MRI is highly dependent on the age of the clot.

• Hyperacute bleeding (<24 hours): T1 isointense, T2 slightly hyperintense

• Acute bleeding (1 to 3 days): T1 slightly hyperintense, T2 hypointense

• Subacute bleeding (>3 days): T1 hyperintense, T2 hypointense (T2 may be hyperintense for late subacute)

– Treatment

• The treatment of choice is correction of coagulopathy, if present, and emergent surgical decompression.¹

• Benefit of surgical intervention is debatable if only symptom is pain.

• Surgery typically involves laminectomy without the need for fusion.

• For cervicothoracic and thoracolumbar junction multilevel laminectomies, consider instrumentation and fusion.

– Surgical pearls

• Subfascial drains may diminish the incidence of symptomatic epidural blood collections following multilevel laminectomy procedures.

Fig. 25.1 T2-weighted MRI of the lumbar spine showing post-operative mixed signal fluid collection (consistent with epidural hematoma) in the epidural space compressing the dural sac.

• Cauda equina syndrome (CES) refers to the clinical condition that results from compressive, ischemic, and/or inflammatory neuropathy of multiple lumbar and sacral nerve roots in the lumbar spinal canal.3,4

• Conus syndrome has features similar to those of CES but involves compression at the level of the conus medullaris (T12-L1 typically).

• The most common cause is disc herniation in the lumbar region.

• It may also be caused by traumatic injury, lumbar spinal stenosis, primary or metastatic tumors, epidural abscess, ankylosing spondylitis, spinal subdural or epidural hematoma, spinal manipulation, and vascular malformation.^3,4

– Signs, symptoms, and physical exam

• Urinary retention is the most consistent finding, occurring in 90% of patients presenting with CES.

• Anal sphincter tone diminished in 80% of patients.

• Saddle anesthesia is the most common sensory deficit (75% of patients).

• Once total perineal anesthesia develops, patient will likely have permanent bladder dysfunction.

• Low back pain and radicular symptoms

• Conus lesions have the same features except that motor and sensory loss is typically asymmetric.

– Workup

• Basic laboratory studies and appropriate neuroimaging

• If imaging demonstrates pathology other than herniated nucleus pulposus (HNP), further workup is indicated (e.g., tumor or infection workup).

• Leukocytosis and fever may be absent.

• Typical finding: T1 shows hypo- or isointense epidural mass; vertebral osteomyelitis shows up as reduced signal in bone. T2 shows high-intensity epidural mass that often enhances with gadolinium but may show minimal enhancement in the acute stage when composed primarily of pus with little granulation tissue.5

• Plain radiographs often helpful for suspected discitis and will show chronic, erosive changes in the end plates.

– Treatment

• For SEAs that show clear involvement of the spinal canal and cause dural compression, surgical decompression and intravenous antibiotic therapy are the treatments of choice.

• SEA is often seen in association with discitis/osteomyelitis. In these cases, typically only a thin film of epidural enhancement is seen. Surgical intervention not necessarily indicated in these situations.

• Patients with severe neurologic deficit may show minimal improvement even with surgical intervention.

• SEA is fatal in up to one-third of elderly patients, and mortality is usually due to the original focus of infection or as a complication of neurologic compromise.

– Surgical pearls

• Most spinal instrumentation is safe, effective, and at times necessary in the treatment of epidural abscess or discitis/osteomyelitis of the spine.

Related posts:

Tumors of the Spine Transpedicular Approach Posterior and Transforaminal Lumbar Interbody Fusion (PLIF/TLIF) (Open) Surgical Resection of Spinal Vascular Lesions Physical Examination Retroperitoneal Approaches to the Thoracolumbar Spine

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