Mishima Hiroyuki, Ayabe Junichi, Takadera Mutsumi, Tsuchiya Yusuke, Kawasaki Taisuke, Okano Masayuki, Isoda Masanori, Tanaka Yoshihide
Department of Neurosurgery, Yokosukakyosai Hospital, Yokosuka, Kanagawa, Japan.
NMC Case Rep J. 2022 Jul 8;9:209-212. doi: 10.2176/jns-nmc.2022-0066. eCollection 2022.
The causes of spinal epidural hematoma (SEH) have been attributed to coagulopathy, trauma, vascular anomalies, and so forth. The incidence of vascular anomalies shown by digital subtraction angiography has been reported to be 15%, and most cases have been reported to be spinal epidural arteriovenous fistulae. SEH has rarely been caused by venous congestion. We report a case of SEH in a 78-year-old male who presented to our emergency department with sudden-onset back pain, followed by complete paraplegia with bladder and rectal disturbance. Magnetic resonance imaging revealed a dorsally placed extradural hematoma extending from T10 to L1. An urgent laminectomy from T11 to L2 was performed. Computed tomography angiography (CTA) performed 1 week after the operation showed compression of the left renal vein between the aorta and superior mesenteric artery with dilation of the surrounding veins, including the spinal epidural venous plexus, at the same level as the hematoma. This was diagnosed as Nutcracker syndrome (NCS), which was consistent as a cause of SEH. The patient's symptoms gradually improved, and after 6 months, he regained normal strength in his lower extremities, but bladder and rectal disturbance remained and required intermittent self-catheterization. We chose conservative treatment for NCS, and SEH did not recur until the patient died of a cause unrelated to SEH or NCS. SEH could occur secondary to venous congestion including NCS. We emphasize the importance of investigating venous return to evaluate the etiology of SEH, which can be clearly visualized using CTA.
脊髓硬膜外血肿（SEH）的病因归因于凝血功能障碍、外伤、血管畸形等。数字减影血管造影显示的血管畸形发生率据报道为15%，且大多数病例据报道为脊髓硬膜外动静脉瘘。SEH很少由静脉淤血引起。我们报告一例78岁男性的SEH病例，该患者因突发背痛就诊于我院急诊科，随后出现完全性截瘫并伴有膀胱和直肠功能障碍。磁共振成像显示硬膜外血肿位于背部，从T10延伸至L1。紧急实施了T11至L2的椎板切除术。术后1周进行的计算机断层血管造影（CTA）显示，在与血肿同一水平，腹主动脉和肠系膜上动脉之间的左肾静脉受压，周围静脉包括脊髓硬膜外静脉丛扩张。这被诊断为胡桃夹综合征（NCS），与SEH的病因相符。患者症状逐渐改善，6个月后下肢恢复正常力量，但膀胱和直肠功能障碍仍然存在，需要间歇性自我导尿。我们对NCS选择了保守治疗，在患者死于与SEH或NCS无关的原因之前，SEH未复发。SEH可能继发于包括NCS在内的静脉淤血。我们强调调查静脉回流以评估SEH病因的重要性，使用CTA可以清晰地观察到静脉回流情况。
