Intracranial epidural hemorrhage during lumbar spinal surgery
Yasuaki Imajo1, Tsukasa Kanchiku1, Hidenori Suzuki1
1Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube City, Japan.
Abstract:
The authors report a case of intracranial epidural hemorrhage (ICEH) during spinal surgery. We could not find ICEH, though we recorded transcranial electrical stimulation motor evoked potentials (TcMEPs). A 35-year-old man was referred for left anterior thigh pain and low back pain that hindered sleep. Sagittal T2-weighted magnetic resonance imaging revealed an intradural tumor at L3-L4 vertebral level. We performed osteoplastic laminectomy and en bloc tumor resection. TcMEPs were intraoperatively recorded at the bilateral abductor digiti minimi (ADM), quadriceps, tibialis anterior and abductor hallucis. When we closed a surgical incision, we were able to record normal TcMEPs in all muscles. The patient did not fully wake up from the anesthesia. He had right-sided unilateral positive ankle clonus 15 min after surgery in spite of bilateral negative of ankle clonus preoperatively. Emergent brain computed tomography scans revealed left epidural hemorrhage. The hematoma was evacuated immediately via a partial craniotomy. There was no restriction of the patient's daily activities 22 months postoperatively. We should pay attention to clinical signs such as headache and neurological findgings such as DTR and ankle clonus for patients with durotomy and cerebrospinal fluid (CSF) leakage. Spine surgeons should know that it was difficult to detect ICEH by monitoring with TcMEPs.
Insights
Intracranial epidural hemorrhage (ICEH) can occur during spinal surgery and may not be detected by transcranial electrical stimulation motor evoked potentials (TcMEPs). Clinical signs like ankle clonus are crucial for diagnosis.
Area of Science:
- Neurosurgery
- Neurology
- Spinal Surgery
Background:
- Intracranial epidural hemorrhage (ICEH) is a rare but serious complication during spinal surgery.
- Transcranial electrical stimulation motor evoked potentials (TcMEPs) are used for intraoperative neuromonitoring.
- Detecting ICEH solely through TcMEPs can be challenging.
Purpose of the Study:
- To report a case of ICEH during spinal surgery.
- To highlight the limitations of TcMEPs in detecting ICEH.
- To emphasize the importance of clinical signs in diagnosing postoperative ICEH.
Main Methods:
- A case study of a 35-year-old male undergoing spinal tumor resection.
- Intraoperative recording of TcMEPs from bilateral abductor digiti minimi, quadriceps, tibialis anterior, and abductor hallucis.
- Postoperative neurological assessment, including ankle clonus, and emergent brain computed tomography (CT).
Main Results:
- Normal TcMEPs were recorded throughout the spinal surgery.
- The patient developed unilateral positive ankle clonus postoperatively, a new neurological finding.
- Emergent brain CT revealed left epidural hemorrhage, which was surgically evacuated.
- The patient had no functional restrictions 22 months postoperatively.
Conclusions:
- Spine surgeons must be aware that TcMEPs may not detect intracranial epidural hemorrhage.
- Clinical signs, such as headache and neurological deficits (e.g., ankle clonus), are critical for early ICEH diagnosis, especially in patients with durotomy and cerebrospinal fluid leakage.
- Prompt recognition and surgical intervention for ICEH are essential for favorable outcomes.
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