- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan
- Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan
- Department of Neurosurgery, Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Chien-Min Chen, Dueng-Yuan Hueng
Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
DOI:10.4103/2152-7806.131106Copyright: © 2014. Po Cheng Y This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Cheng Y, Lee K, Lin P, Huang AP, Cheng C, Ma H, Chen C, Hueng D. Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation. Surg Neurol Int 19-Apr-2014;5:55
How to cite this URL: Cheng Y, Lee K, Lin P, Huang AP, Cheng C, Ma H, Chen C, Hueng D. Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation. Surg Neurol Int 19-Apr-2014;5:55. Available from: http://sni.wpengine.com/surgicalint_articles/full-endoscopic-interlaminar-removal-of-chronic-lumbar-epidural-hematoma-after-spinal-manipulation/
Background:Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature.
Methods:We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany).
Results:After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up.
Conclusions:Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.
Keywords: Chronic epidural hematoma, endoscopic, interlaminar, lumbar, spinal manipulation
Lower back pain treatments can vary greatly. Among them, spinal manipulation is widely used. Complications associated with spinal manipulation are frequently seen in the cervical region, as well as some in the lumbar region. Solheim et al.[
The patient was a 63-year-old male with no obvious illness. He had back pain that lasted for 1 year before his first outpatient department (OPD) visit and was not associated with any traumatic episode. No coagulation disorders or anticoagulation medication had been used. Before his first OPD visit, he had already tried medical treatment for 3 months, but mild to moderate back pain still gave him discomfort and was found to be bothersome. Lumbar plain file was arranged and showed no spondylolisthesis or fracture was observed. Magnetic resonance imaging (MRI) revealed only mild bulging disc over the L4-5 L5-S1 and no spinal stenosis was discovered [
Full endoscopic views: (a) A working channel was inserted after flavum ligament opened. (b) An encapsulated hematoma was found. (c) The hematoma was punctured. (d) Ellman bipolar flexible radiofrequency probe tip is activated over the bleeding points around the hematoma once hematoma is removed
After surgery, the patient's left leg pain immediately improved. MRI follow-up 10 days after the surgery revealed no residual hematoma [
Lumbar EDH with neurologic deficit usually requires surgical intervention to decompress the nerve root and spinal canal. Conservative treatment may be considered in cases of mild neurologic deficit patients,[
The clinical presentation of lumbar EDH is variable. In our case, a patient who suffered from left leg pain gradually after spinal manipulation made us aware of the possibility of traumatic or secondary lumbar EDH. Also, the leg pain becoming gradually intolerable hinted to us the chronic level of this situation. An MRI is the preferred diagnostic tool for lumbar EDH, which can reveal the location and extension of the hematoma and the degree of lumbar nerve root compression. Although in the lumbar region, encapsulated spaces lacking a capillary network may have a different time course in MRI signal presentation as compared with that in parenchymatous organs such as the brain. The MRI presentation of the hematoma related to the hematoma stage could roughly be predicted.[
Surgical intervention to decompress the nerve root and spinal canal is considered if neurologic deficit progression is observed and it becomes unbearable. The traditional open procedure for lumbar decompression uses a midline approach. Bilateral subperiosteal dissection of the paraspinal muscles is performed followed by removal of the spinous process and lamina to expose the lumbar canal. Hemilaminectomy to keep the spinous process intact and supraspinous ligament continuality is generally chosen when possible. Recent advances in minimal access techniques by using muscle-splitting nonexpandable or expandable tubular retractors have benefits, which include decreased pain, decreased blood loss, lower rates of infection, and preservation of the normal biomechanics of the spine.[
Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. Although lumbar laminectomy to decompress the spinal canal or root is the mainstream management in those with neurologic deficits caused by EDH, a percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.
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