Spinal Epidural Hematoma¶

Definition¶

A spinal epidural hematoma (SEH) is a collection of blood in the epidural space — between the dura mater and the vertebral periosteum/posterior longitudinal ligament. In the trauma setting, SEH results from disruption of the epidural venous plexus (Batson plexus) or from fracture-related arterial bleeding. SEH can compress the spinal cord or cauda equina, causing acute neurological deterioration that may require emergent surgical evacuation.

Etiology in Trauma¶

Traumatic SEH results from:

• Vertebral body fractures with bleeding from fractured cancellous bone
• Disruption of the epidural venous plexus during spinal trauma
• Vascular injury from fracture fragments or ligamentous disruption
• Rarely, vertebral artery injury with epidural extension

Non-traumatic causes (anticoagulation, coagulopathy, spinal procedures, vascular malformations) are discussed elsewhere but should be considered in the differential.

Imaging Findings¶

MRI¶

MRI is the study of choice for diagnosing spinal epidural hematoma:

• T1-weighted — Isointense to slightly hyperintense to the cord in the acute phase; becomes hyperintense (bright) in the subacute phase as methemoglobin forms
• T2-weighted — Variable signal depending on the age of the hematoma. Acute hematoma may be isointense or slightly hyperintense. Hyperacute blood is bright on T2.
• Location — Epidural hematomas are typically posterior or posterolateral in the spinal canal, conform to the shape of the epidural space, and may extend over multiple vertebral segments
• Cord compression — Displacement and compression of the thecal sac and spinal cord
• The hematoma does not cross the midline anteriorly (where the PLL is adherent to the dura) but can extend posteriorly and laterally

CT¶

• A hyperdense (fresh blood) collection in the epidural space may be visible on CT, particularly on axial images
• Less sensitive than MRI, especially for small hematomas or those in the thoracic spine
• CT is often the first study obtained in trauma and may provide the initial clue

Clinical Presentation¶

• Back pain at the level of the hematoma
• Progressive neurological deficit — weakness, sensory loss, bowel/bladder dysfunction
• Symptoms may develop acutely (minutes to hours) or subacutely (hours to days)
• Neurological deterioration may occur after an initial "lucid interval" following trauma

Management¶

• Small, asymptomatic hematomas — Conservative management with close neurological monitoring and serial MRI
• Symptomatic hematomas causing cord compression — Emergent surgical decompressive laminectomy and hematoma evacuation
• Timing of surgery is critical — outcomes are better when decompression is performed within 12–24 hours of symptom onset
• Correct any coagulopathy (anticoagulants, thrombocytopenia)

Key Points¶

• Spinal epidural hematoma is a collection of blood in the epidural space that can compress the cord or cauda equina
• MRI is the study of choice — the hematoma is typically posterior/posterolateral and extends over multiple levels
• Progressive neurological deterioration in a trauma patient should prompt urgent MRI
• Emergent surgical decompression within 12–24 hours is associated with better outcomes
• CT may show the hematoma but is less sensitive than MRI

References¶

1. Pierce JL, Donahue JH, Nacey NC, et al. Spinal Hematomas: What a Radiologist Needs to Know. RadioGraphics. 2018;38(5):1516-1535. doi:10.1148/rg.2018180099. PubMed
2. Moriarty HK, Cearbhaill RO, Moriarty PD, Stanley E, Lawler LP, Kavanagh EC. MR imaging of spinal haematoma: a pictorial review. British Journal of Radiology. 2019;92(1095):20180532. doi:10.1259/bjr.20180532. PMC
3. Figueroa J, DeVine JG. Spontaneous spinal epidural hematoma: literature review. Journal of Spine Surgery. 2017;3(1):58-63. doi:10.21037/jss.2017.02.04. PMC
4. Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. European Journal of Radiology. 2007;64(1):119-125. doi:10.1016/j.ejrad.2007.02.014. PubMed
5. Dziedzic T, Kunert P, Krych P, Marchel A. Management and neurological outcome of spontaneous spinal epidural hematoma. Journal of Clinical Neuroscience. 2015;22(4):726-729. doi:10.1016/j.jocn.2014.11.010. PubMed
6. Fedor M, Kim ES, Ding K, Muizelaar JP, Kim KD. Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature. Korean Journal of Spine. 2011;8(4):272-282. doi:10.14245/kjs.2011.8.4.272. PMC
7. Spinal epidural hematoma. Radiopaedia.org. https://radiopaedia.org/articles/spinal-epidural-hematoma-2

Related Articles¶

• Spinal Cord Injury Imaging
• Spine Trauma Imaging Approach