Definitive treatment is elusive
Several authors advocate emergent surgical decompression and evacuation of the hematoma, because the neurological outcome could be catastrophic,7 resulting in complete quadri/paraplegia. This approach is equivocal, however, as spontaneous resolution of neurological symptoms has been described in many cases.1,7-11 Therefore, the decision whether to operate largely depends on the individual’s surgical risk factors and clinical course. In a high-risk patient who is improving neurologically, watchful waiting may be prudent, while in neurologically deteriorating low-risk cases little is lost with immediate surgical decompression.12
The prognosis of SSEH is also difficult to estimate. Several reports confirm that cervical and cervicothoracic hematomas carry a worse prognosis than thoracolumbar and lumbosacral hematomas.3,5 A rapid onset of neurological deterioration (less than12 hours) also heralds graver consequences, as does spinal cord edema on initial MRI.5
Two windows of opportunity
Two time periods stand out as possible course-changing opportunities for clinicians.The first occurs when the patient initially complains of an acute backache. At this point, ACP/APS guidelines direct us to look for red flags that focus attention on the more troubling etiologies for backache.6 Unfortunately, SSEH has no specific red flag, and itis misleading to suggest that such an esoteric diagnosis should routinely be considered.
A better approach would be to look for the unusual: very sharp, acute-onset, highly localized back pain that does not respond well to analgesics (TABLE [developed by NR]),along with any dysesthesia or unusual radicular complaint. A positive l’hermitte sign—anelectrical sensation that runs down the back and into the limbs—on physical examination might also warrant placing SSEH in the differential diagnosis.
The second time when swiftness might be crucial is from diagnosis to surgery. In a neurologically deteriorating patient, time is of utmost importance, and taking action at this juncture can produce a marked difference in the final outcome.3
CORRESPONDENCE
Nimrod Rahamimov, MD, Department of Orthopedics Band Spine Surgery, Western Galilee Hospital, PO Box 21, Naharia 22100, Israel; Nimrod.Rahamimov@naharia.health.gov.il