Spontaneous Spinal Epidural Haematomas in Adults: A Systematic Review

Study design: Systematic review Objectives: Understand the typical presentation, risk factors, location, size, treatment and outcome of spontaneous spinal epidural haematomas (SSEH). Methods: Systematic review of the English literature from 1 January 1960 to 1 March 2018. Individual patient data was extracted and collated. Outcome measures were mode of presentation, risk factors, initial neurological findings, presumed diagnosis, diagnostic investigations, site and size of the SSEH, treatment, neurological recovery and survival. Results: 160 publications (254 patients) were reviewed. Most patients (98%) presented with back pain and radicular pain. Pregnancy was common in those aged under 40years (24%), whereas anticoagulation therapy (30%) and hypertension (30%) was common in those aged 50-80years. Most patients present with neurological dysfunction. 15% were initially suspected of having an alternative diagnosis, including 7.5% who were suspected of ischaemia for which anti-coagulation therapy was either planned or given. MRI and/or CT myelogram was performed in 98% of cases. The mid-cervical spine and cervico-thoracic junction were most commonly affected and the average haematoma size extended across 5.4 vertebral levels. Most patients underwent surgical decompression (76%) and most improved their neurological function (85%). Conclusions: SSEH affects all age groups and presents with variable neurological signs sometimes mimicking cerebral or cardiac ischaemia. Cross-sectional spinal imaging with MRI or CT is diagnostic and avoids inappropriate anticoagulation therapy. Most SSEHs are located in the mid-cervical spine and cervico-thoracic junction and affect multiple spinal levels. Surgical intervention is not always indicated, but with appropriate management most patients will improve or resolve their neurological deficit.