Radiographic Exhibit



Spinal Subdural Hematoma 1 Joel Sokoloff, M.D., Marc N. Coel, M.D., and Ronald J. Ignelzi, M.D.

The authors report a case of subacute spinal subdural hematoma in a patient with ankylosing spondylitis. Only 18 such cases have been reported in the nonradiological literature. Early diagnosis is imperative in order to minimize neurological sequelae. INDEX TERMS: Meninges, wounds and injuries. Myelography, indications • Spinal Cord. wounds and injuries

Radiology 120:116, July 1976

hematomas are rare. Eighteen cases have been reported in the nonradloloqlcal literature, of which 5 were unsuspected and discovered postmortem. Early diagnosis is imperative in order to minimize neurological sequelae. A case of subacute spinal subdural hematoma in a patient with severe ankylosing spondylitis is presented below.

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PIN A L SUBDURAL

CASE REPORT G. G., a 56-year-old white man with a 30-year history of ankylosing spondylitis, was admitted complaining of low back pain and of inability to walk for a week. One month earlier he had fallen forward, and several days later he noticed gradual onset of weakness in his legs, progressing to paraplegia. Neurological examination was normal. Radiographs of the spine revealed severe ankylosing spondylitis with no fracture. Physical examination disclosed a sensory deficit from T 12 caudad. The patient was unable to move his lower extremities, and deep tendon reflexes were decreased. Myelography demonstrated a T12-L 1 "intradural extramedullary defect" (Fig. 1). Decompressive laminectomy was performed and a subdural hematoma was evacuated. Immediately after the operation the patient was able to move his toes, but one week later he could no longer do 50. Fluoroscopy of the spine demonstrated no obstruction to the flow of residual Pantopaque and no evidence of a mass. DISCUSSION Edelson et al. (1) and Zilkha and Nicoletti (2) reviewed 18 cases of spinal subdural hematoma in patients ranging from 6 months to 77 years of age (median age, 40 yr.). Of the 9 patients who were 26 or younger, 1 had hemophilia and 6 had leukemia with thrombocytopenia. Three had thrombocytopenia alone, and 1 was undergoing anticoagulant therapy. Spinal subdural hematomas were discovered following lumbar puncture in 10 patients, 9 of whom had thrombocytopenia. Five were found at postmortem examination in patients who had undergone lumbar puncture just prior to death. Most of the patients 40 or older had had minor trauma, usually a fall, prior to the discovery of the hematoma. None had a known bleeding diathesis. It is possible that unusual forces caused by minor trauma to the fused spine in severe ankylosing spondylitis were responsible for the development of the subdural hematoma in our patient. Symptoms generally progressed for several days before medical attention was obtained. Neurological symptoms and signs varied from minor sensory and motor abnormalities to paraplegia. Myelography was successful in 10 of 11 patients. An apparent extradural defect was present in only 1 of the 5 cases illustrated in the literature; the other 4 had intradural extramedullary lesions. In our case, an eccentric filling defect with

Fig. 1. Myelogram showing subdural hematoma. A. APview. Notethe sharp transitional zones usuallyassociatedwith intradural lesions (arrows). B. Lateral view, reversed in order to enhance contrast. Note the anterior mass, whose configuration suggestsan extradural lesion. sharp transitional zones also suggested an intradural extramedullary abnormality. Surgery was performed in 8 of the 18 patients; one patient died in the early postoperative period. There was complete recovery in 5 and little or no improvement in 2. It is clear that myelography and surgery should be performed as soon as possible in patients with subdural or extradural hematoma in order to prevent development or persistence of severe neurological deficits, and one should be aware of the possibility of hematoma formation in patients ranging from those without apparent predisposition to those with coagulopathy following lumbar puncture.

University Hospital 225 W. Dickinson St. San Diego, Calif. 92103 REFERENCES 1. Edelson RN,Chernik NL, PosnerJB: Spinal subduralhematomascomplicating lumbarpuncture. Arch NeuroI31:134-137, Aug 1974 2. Zilkha A, Nicoletti JM: Acute spinal subdural hematoma. Case report. J Neurosurg 41:627-630, Nov 1974

~om the Departmentsof Radiology (N.S., M.N.C.) and Neurosurgery (R.J.I.), University of California Medical Center, San Diego, Calif., a~d Veterans Administration Hospital,La Jolla, Calif. Accepted for publication in February 1976. sJh 116

Spinal subdural hematoma.

Radiographic Exhibit • Spinal Subdural Hematoma 1 Joel Sokoloff, M.D., Marc N. Coel, M.D., and Ronald J. Ignelzi, M.D. The authors report a case of...
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