Tiirkish Neiirosiirgery 11: 73 - 77, 2001 Tiisdeiiiir: Spiiiiil SIlIH/iiml Hemiitomii

LumbarComplication

Spinal Subdural Hematomaof Lumbar Discectomy (Case

as aReport)

SpinalBirOlarak Gelisen~Sunumu

Diskektomi KomplikasyonuSubdural Hematom: Olgu

Lumber

EROL T ASDEMIROGLU, HALIT S. TOGA Y

Istanbul Social Security Hospital, Neurosurgery Service, Istanbul, Türkiye

Received : 22.3.1999 <::> Accepted : 22.10.1999

Abstract: This repOit describes the case of 49-year-oldfemale patient who developed a lumbar spinal subduralhematoma as a complication of lumbar discectomy. Wegive the details of the case and review the relevantliterature.Our conclusion is that spinal subdural hematomashould be considered a possible postoperarivecomplication of lumbar discectomy if radicular pain andback pain recur soan after a patient has undergone asuccessful surgery of lumbar di sc hemiation.

Özet: Lomber disk hemisi operasyonunun komplikasyonuolarak gelisen bir spinal subdural hematom olgususunuldu. Literatür gözden geçirildi ve olgu tartisildi.Basarili bir lomber diskektomi operasyonunu takibenortaya çikan bel agrisi ve radiküler tip bacak agrisininspinal subdural hematoma bagli olabilecegi vurgulandive spinal subdural hematomun postaperatif dönemdetekrar olusan bel ve bacak agrisinin ayiriCl tanisinda gözönüne alinmasi gerektigi vurgulandi.

Key Words: Lumbar di sc surgery, postoperativecomplication, spinal subdural hematoma

Anahtar Kelimeler: Lomber disk hemisi, postoperatifkomplikasyon, spinal subdural hematoma

INTRODUCTION

Spinal subdural hematoma was first describedby Potts in 1910 (ll) and Harris in 1911 (5) in two

consecutive case reports. In 19481 Schiller et al (lS)pubhshed the first detailed report on a case of aspinal subdural hematoma.

it has long be en recognized that hematomas inthe spinal canal can produce sudden spinal cord

andi or cauda equina compression (LO). Investigatorshave linked the development of these lesions to a

variety of factorsi including ruptured vascular

ma1formationsl existing neoplasm, hypertensionicoagulopathyi traumai pregnancyi old age, infection,anticoagulant therapy (especially when combinedwith spinal puncture or epidural anesthesia)i and

following ventriculo-peritoeal shunt placement andlumbar discectomy (1/8-12/14,15,17). Spinalhematomas can also occur spontaneously and mayeven develop af ter sudden movements such assneezing or coughing (LO). Most spinal subduralhematomas are detected in the acute phase (within48 hours of the event), but some have been known

to cause chronic myelopathy (2). Spinal subduralhematomas usually produce severe irreversible

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Tiirkish Neiirosiirgery 11: 73 - 77, 2001

neurological deficits, and these compressiye lesionsalways require immediate surgical evacuation.However, some spinal hematomas have been knownto resolve spontaneously (6) and treatment by seriallumbar spinal taps and drainage has also beeneffectiye (7).

Here we present a case of postoperative spinalsubdural hematoma, that developed as an unusual

complication of lumbar disc surgery. The hematomawas diagnosed by lumbar magnetic resonance (MR)

imaging and iand the patient responded to oralsteroid treatment.

CASE REPORT

A 49-year-old woman was admitted to theNeurosurgery Service at Eyüp Social SecurityHospital in January of 1997. She had been sufferingright leg and hip pain for 4 months. Her medical andsurgical histories were unremarkable, and herphysical exam and vital signs were normaL. A

Tasdeiili,.: Spiiial Siihdiiml Heiiia/oiiia

neurological exam showed positive Straight LegRaising on 30 degrees, decreased ankle jerk reflexand subnormal strength of dorsal flexion of the footon the right side. These findings were consisted withright L5 radiculopathy. An axial computedtomography (CT) sean of the lumber spine showedL4-5 disc herniation . We performed right L4-5discectomy via the classical approach. The patient'sright leg pain improved immediately, and she wasmobilized the day af ter surgery. However, on thesecond postoperative day her right leg pain returned.The patient's neurological exam was normal, but herright leg pain persisted and iesponded onlyminimally to nonsteroidal antiinflammatorymedications. To rule out the possibility of havingmissed fragment of extruded disc during surgery,we performed, gadolinium-OTPA-enhanced MRimaging of the lumbar spine on the postoperativeday 7. The sean revealed a posteriorly located spinalsubdural hematoma extending from Ll to S2. We

noted postoperative changes at L4-5 , but there wasno residual disc fragment nor any evidence of nerve

Figures lA and lB. Tl-weighted sagittal MR images of the lumbar spine on postoperative day 7 without (A) and with (B)gadoliniurn enhancernent show a subdural collection in the posterior aspect of the dural sac and cauda equina.The lesion extends from L2 to S2.

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TiirkisJi Neiirosiirgery 11: 73 - 77, 2001

root compression (Figures lA,B &Figure 2). Weprescribed oral steroid therapy of 4 mgdexamethasone four times daily for 20 days, andthen tapered this to 4 mg every fifth day. Thepatient's symptoms subsided signifieantly in oneweek and her right leg pain eventualJy disappearedaltogether. The 5 months a follow-up neurologicalexam and MR imagIi1g of the lumbar spine werenormal (Figure 3).

DISCUSSION

Symptomatic spinal subdural hematoma is avery unusual compIieation of lumbar disc surgery.This type of lesion has been detected after trauma,nad in the settings of eoagulopathy andarteriovenous malformation (9). it has also been seenin surgical eases after removal of spinal araehnoideysts. However one case by Reinsel et aL. (12) hasbeen described the development of spinal subduralhematoma after lumbar disc surgery. Most

Figure 2. T2-weighted sagittal MR images of the lumbarspine on postoperative day 7 show a subduralcollection at this hypointense to the spinal cordwhite matter.

Tasdemir: Spi/inl Siibdiiral Hematoiiia

documented spinal subdural hematomas, the latterease included have been treated with immediate

evacuation via laminectomy in order to preserve orrestore neural function. However, spontaneousresolution (6) and treatment by serial spinallumbarpuneture and drainage have also been reported (7).Our patient's neurologieal status was normalotherthan severe leg pain. Oral steroids effeetively treatedher symptoms and helped resolve the subduralhematoma.

The meehanism behind hematoma formation

in the spinal subdural space is not fully understood.Arecent eleetron microscopy study by Haines andcolleagues (4) offered an explanation for howsubdural hematomas develop in the brain, and thistheory could also apply to the spine. The authorsdiscovered that the dura mater is composed of twolayers, the externallayer being strong and the Iimer"meningeal dura",also known as the dural bordercell layer, being structuralJy weak and vulnerable

Figure 3. Sagittal Tl-weighted sagittal MR imaging of thelumbar spine at the fifth postoperative monthshowed that the patient's subdural hematomahad eompletely disappeared.

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Tiirkish Neiirosiirgery 11: 73 - 77, 2001

to tears. In the spinal dura, this type of injury couldoccur during nerve root and dural sac retraction indisc surgery. Once the arachnoid membrane is tomany hemorrhage in the region could spread throughthe area. This would form an extensive discrete

hematama along the spinal canal in the "eleaved­open" space between the tough extemal dura andarachnoid membrane.

MR imaging is the method of choice fordetecting spinal hematomas since it offers manyadvantages over myelography and axial CT scan(10,12,13). Lumbar MR scans make detection ofsubacute spinal subdural hematomas relativelyeasy,and compared to CT provide better definitian of theboundaries of these lesions (lO,12). Al hema torna inthe subdural space will appear clumped andloculated producing an MR image similar to that ofmyelographic contrast at the site after subduralinjection. The diagnosis is confirmed when changingthe patient's pasition does not cause the subduralbload to relocate or diffuse freely. These hematomasare usually located at the anterior or posterior aspectof the spinal canal, but sametimes encirele the spinalcord in the subdural space.

The signal characteristics of spinal subduralhematomas are similar to those of acute and subacute

hematomas of the brain (16). In the early subacutestage (3-7 days of subdural bleeding) theintracellular iron-hemoglobin in the hematamachanges to intracellular iron-methemoglobin. At thisstage intracellular iran is hyperintense to brainparenchyma on T1-weighted MR images, andhypointense to brain parenchyma on T2-weightedMR images. On gradient-echo or T2-weightedimages of acute spinal subdural collections, thepresence of deoxyhemoglobin produces law signalintensity over the majority of the lesion. In additionto elues about the nature of the hematama, MR scansalsa yield information on the extent of the lesionand the degree of cord and cauda equinacompressian that is involved.

In our patient, T2-weighted sagittal MR imagesrevealed an intradural collection at L2 to S2 that was

located posterior to the cauda equina and washypoin tense to brain parench yma (Fig 2).Gadolinium-enhanced Tl-weighted sagittal MRimages revealed that the collection was hyperintenseto normal brain and showed contrast enhancement

at the lesion margins (Figures lA and lE).

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Tasdemir: Spiiin/ Siibdiirnl Hematonin

The diagnosed subacute spinal subduralhemato::na was causing radicular pa in, whichresolved with steroid therapy. We believe that thishematama was induced by trauma during surgery.The damage stimulated a secondary inflammatoryresponse in the subdural space, involving granulationtissue formatian and neovascularization. Since the

progression of subdural hematama is aninflammatory process, steroids offer benefits byinhibiting the reaction (3). Based on our findings itappears that steroid treatment may decrease boththe inflammatory response and any associated pa inthat is chemically mediated.

We conelude that spinal subdural hematamashould be considered a possible postoperativecomplication of lumbar disc surgery. MR imaging isthe diagnostic method of choice when this type oflesion is suspected. if the patient has no neurologicalabnormalities other than pain, oral steroid therapycan offer effective pain relief.

Correspondence: Erol TasdemirogluIncirli Caddesi, Deniz Apt. 74/7,Bakirköy, Istanbul,Türkiye.Phone&fax: 90 (212) 542-88

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