Rare clinical: spontaneous spinal hard membrane hematoma

Spontaneous Spinural Hematoma (SSEH) is an unknown cause, acute episodes of neck or back pain, and fast progressive nerve root or spinal cord compression.

It is rare clinically, with a prevalence of about one million.However, most of the patients are developing rapidly, and sometimes emergency surgery is needed.

Due to SSEH’s lack of epidemiological survey data based on crowds, clinicians have a serious lack of understanding of the disease. It is easy to miss the best treatment time, leaving patients with difficulty recovering neurological dysfunction, such as paralysis.

Clinical characteristics

SSEH is more common in neck and chest and chest and waist segments. Men develop more than women, because the abdominal side and vertebral body of the duct.Extrathleal hematoma occurs on the back side. Typical manifestations are sudden back tingling, while symptoms of spinal cord or nerve compression. Then there are different degrees of exercise and (or) sensory disorders below the pain.For whole paralysis.There are also a few patients with the above-mentioned typical symptoms, such as Brown-Sequard syndrome.SSEH’s onset speed is generally relatively rapid, and severe spinal cord or neurological dysfunction can occur within a few hours or days.


Diagnose the first choice of spine MRI examination.MRI sagittal hematoma is crescent, long strip -shaped, or shuttle abnormal signal.Limited people are mirror -shaped, the base is wide, and the realm is clear.The horizontal section is crescently wrapped around the back of the duct or abdomen, which can accumulate several vertebral bodies.Young people are often located in the neck and chest segments; elderly people are often located in the lower chest segment and below.

Typical SSEH has the characteristics of various periods of hematoma and is not difficult to diagnose.The evolution of its signal is roughly divided into 4 stages on MRI:

Super -acute period (<24 h): T1 and other signals, T2 high signals

Acute period (1 ~ 3 d): T1 and other signals, T2 low signals

Early subacute (1 ~ 7 d): T1 high signal, T2 low signal

Substable late period (7-14 d): T1 and T2 are high signals.

Chronic period (after 14 d): T1 and T2 are high signals

A small number of cases are mixed manifestations because in the hematoma of the same patient, bleeding mixed in different periods, often a certain period of signal, mixed with other period signals, so that the signal is mixed and it is difficult to recognize.On the basis of mastering the characteristics of SSEH hematoma in each phase, combining the bleeding time of patients, especially the time when the symptoms are aggravated or the symptoms are repeated, it is very helpful for identifying mixed signals.

Figure: C5-7 back-side spontaneous hematoma (arrow)

Figure: C2-L1 hard membrane abdominal hematoma

Figure: T8-L5 Back-side hematoma (arrow)

Figure: C2-T8 hard membrane abdominal hematoma (arrow)

Figure: C3-T2 hard membrane back-side hematoma.E and F are absorbed by hematoma after 1 week of conservative treatment.

Figure: C2-C6 Holilica back-side hematoma is accompanied by Brown-Sequard syndrome

In addition, SSEH’s hematoma is generally not strengthened, which is an important sign that distinguish between tumors.In the subacute period and chronic stage, the hematoma wall can be reinforced by a ring -shaped, while the tumor is reinforced by the entire tumor.

Some scholars suggest that SSEH routine DSA to eliminate vascular malformations or hemangioma. However, vascular malformation rupture causes SSEH literature to account for less than 7 % of all SSEH related reports, and DSA is a creative examination, which can delay the timing of surgery.Comprehensive consideration, only when the MRI examination indicates that the possibility of vascular malformation is high, this creative examination has a certain significance.

Meta analysis

Due to SSEH’s rare clinical clinical, most literature at home and abroad appears in the form of case reports. It still lacks the analysis of large cases, and it is difficult to systematically summarize its risk factors and prognosis correlation.Recently, an individual patient data (IPD) META analysis was systematically reviewed. As of September 1, 2014, cases of pregnancy, hemophilia, and conservative treatment were found. A total of 487 magazine articles reported reports.741 cases of simple SSEH surgery were excluded, and cases of incomplete data were excluded. Finally, the SSEH cases of 617 surgery were included in the study.It is considered a large amount of samples and published in the Neurology magazine, which is highly influential factor, and the conclusion is relatively reliable.

turn out:

As the age increases, the incidence of SSEH is getting higher and higher, with an average age of 58.

The use of anticoagulants is a risk factor for SSEH, and the use of platelet inhibitors is not.

Hypertension and cardiovascular disease are not independent risk factor for SSEH, but they are accompanied by cardiovascular disease, and the prognosis is poor.

Hematoma involves patients with 3-4 segments, and there are often better prognosis.

Compared with other segments, the hematoma occurs in the middle chest, and the prognosis is the worst.

For the time interval from the onset to surgery, it is not the prognosis of emergency surgery within 12 hours. The prognosis of SSEH is mainly related to the degree of neurological dysfunction before surgery. However, severe neurological patients may also recover after surgery.

The source of bleeding is mainly venous.


At present, most scholars advocate early vertebral pressure decompression and clearing hematoma in order to obtain neurological recovery.Some scholars even believe that surgical treatment is the first choice for patients with SSEH.However, some scholars have successively reported the case of conservative treatment of SSEH, and have obtained more satisfactory results.

In the principle of conservative treatment, some cases may occur in the early stage of neuropathy and hematoma absorption.The possible mechanism is "hematoma diffusion" and "hematoma leakage".The former refers to the spread of blood swelling along the outer gap of the duct, which "decreases by itself". The latter means that hematoma can be partially leaked from the intervertebral pores, which reduces the internal pressure of the spinal canal and reduces the spinal cord and nerve compression.

Therefore, some scholars summarize the following situations and feasible conservative treatment:

The patient’s nerve function is less damaged.

AISA grades or Frankel class C/D, but the nerve function is gradually recovered;

Early neurological function recovered after the onset and improved sexually;

Those who have obvious surgery taboos.

Conservative treatment strategies are mainly:

Strictly observe the changes in the function of the nervous system and the change of imaging, be ready for emergency surgery. Once the condition is aggravated, surgical treatment can be treated in a timely manner;

Remove the cause: If you can clarify the cause or risk factors of SSEH, you can treat incentives.Streaming and bed rest, try to avoid the movement that causes increased thoracic and abdominal pressure, avoid stimulating factors such as trauma, fluctuations;

Hormonal treatment is an important method for treating acute spinal cord injury, and it requires large -dose hormones.For SSEH patients with conservative treatment, there are currently no literature that clearly recommend the specific application of hormone categories and dosage, but most scholars recognize the role of hormones in conservative treatment;

Desequent and neurotic nutrition;

High -pressure oxygen treatment;

Pain, right and strengthening care;

Neurreal treatment: For SSEH patients with slower neurological recovery or some neurological dysfunction, it can accept the system’s neurological rehabilitation treatment to reduce sequelae.

Recently, the Zhu Tao team of the General Hospital of Tianjin Medical University summarized 42 cases of SSEH patients (large number of cases) and found that the ASIA classified SSEH patients who aggravated the ASIA grades A, B, C -level or neurological dysfunction, and aggravated.Surgical treatment should be performed as soon as possible; patients who are graded as D or E or E -level, or patients with a trend of improvement in neurological function in the short term, can choose conservative treatment.The higher the ASIA classification of patients with surgical treatment, the shorter the interval between the onset to the surgery, the better the prognosis.Patients with conservative treatment, the higher the grading of ASIA before treatment, the better the prognosis.The conservative treatment group discovered that the hematoma was completely absorbed 3 to 19 d, and the average was 13.3 d.At the same time, it is also pointed out that in terms of surgery, most scholars believe that dewlocarming can reach good prognosis, but whether the vertebral body is fixed and whether the vertebrae slate is still different.


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