Spontaneous spinal subdural hematoma in a young adult with hemophilia

Spontaneous spinal subdural hemorrhage is a rare clinical problem that usually manifests with a sudden onset of pain and paralysis. This article reports on an 18-year-old male with hemophilia A and cerebral palsy, who experienced a several month history of transient back, hip, and leg pain accompanied by gait difficulties that ultimately culminated in a more striking episode of lower extremity weakness, irritability, and diffuse pain involving the neck, back, and legs. In the absence of any clinical or radiographic evidence of hemarthrosis, osteomyelitis, or intracranial hemorrhage, imaging of the spine disclosed a large, apparently multicompartmentalized intraspinal lesion, consistent with old hemorrhage. This extended from the thoracic to the sacral region, with the largest extent at the lumbosacral junction. Following correction of factor VIII levels, surgical exploration was undertaken and demonstrated liquefied blood within the subdural space without violation of the underlying arachnoid. Because the chronic subdural blood flowed quite easily through the dural opening by simply angling the operating table, a limited exposure was required to achieve a substantial evacuation of the clot. This case calls attention to the often protean manifestations of this process, the potential for a chronic course to the clinical symptoms, and the possibility of achieving substantial clot evacuation and clinical recovery with a limited operative approach.