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A 70 year old Afro-Caribbean man presented with sudden onset of neck pain and the subsequent development of progressive right sided weakness and numbness in his right leg. On examination he was an obese man with a blood pressure of 234/136 mm Hg while lying down. The patient's Glasgow Coma Score was 15. He had grade 4/5 power in his right arm and grade 3/5 in his right leg. Fine touch sensation was reduced in his right leg. It was painful to move his neck in all directions and the range of movement was reduced. Plain films of the neck showed degenerative change, without evidence of malignancy. Baseline blood analyses, including a platelet count and coagulation screen were normal. Computed tomography of the patient's head was negative for subarachnoid blood. On returning from the scanning unit the patient reported that the numbness had spread to his abdomen. Initially this was at the T10 level but it progressed to T6. Emergency magnetic resonance imaging (MRI) of the patient's cervical spine was requested (fig 1). This revealed an epidural haematoma at the level of C3, causing cord compression and anterolateral shift. The patient underwent cervical laminectomy and evacuation of epidural haematoma. He made a full neurological recovery and was discharged home exactly six weeks after admission. Histopathological examination revealed only fresh clot.
Spinal cord compression needs to be diagnosed early as the more advanced the myelopathy at presentation, the worse the prognosis. This medical emergency poses particular problems for accident and emergency (A&E) staff as subtle early signs can be obscured further by painful underlying lesions. Spinal epidural haematomata may be either primary (spontaneous) or secondary. Trauma, including epidural puncture, arteriovenous malformations, bleeding disorders and spinal tumours are listed among the secondary causes. Spontaneous spinal epidural haematomata are rare with an estimated incidence of 0.1 case per 100 000 population per year.1
MRI is the investigation of choice to confirm the diagnosis of spinal epidural haematomata. Despite limitations in terms of technical factors, cost and availability, MRI can help define the nature and extent of the spinal epidural haematomata as well as the degree of cord compression. As the soft tissue contrast resolution is superior for MRI than other investigations such as computed tomography, smaller and less clinically significant spinal epidural haematomata will be diagnosed and surgery may not always be necessary. Spinal epidural haematomata show variable signal intensity, being isointense to slightly hyperintense on T1 weighted images and hyperintense with areas of hypointensity on T2 weighted images. On gradient echo images a low signal curved line delineating fresh blood silhouetted against the dural sac is said to be a useful sign.2 Computed tomography remains useful if MRI is unavailable.
In the correct clinical setting, a spinal epidural haematoma is important to consider in the differential diagnosis of acute neck or back pain. Spinal cord compression can be a difficult diagnosis to make in the A&E department. Subtle signs need to be carefully looked for when the history raises compression as a possible diagnosis. The absence of signs does not outrule the diagnosis and, when symptoms are suggestive but signs are lacking, early consultation with the relevant specialty is appropriate. Prompt diagnosis and improved prognosis may depend on urgent access to advanced imaging techniques such as MRI.