Thoracic spinal subdural hematoma after spinal cord stimulation trial: a case report

Spinal subdural hematoma (SSDH) is a rare but potentially serious condition characterized by a compressive accumulation of blood within the thecal sac. It may result from trauma, surgery, or underlying vascular abnormalities, often associated with anticoagulant use. In this case, SSDH was diagnosed post-implantation of a spinal cord stimulation (SCS). Current estimates suggest that a neuraxial (including epidural) hematoma following SCS occurs in about 0.32% of cases, with no reported sub/intradural pathology from uncomplicated SCS procedures.

We report a case of SSDH in a 78-year-old male, diagnosed after a percutaneous dorsal column stimulator trial for chronic postherpetic thoracic neuralgia. The patient presented with days of weakness and gait instability, 1 month post-SCS trial. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed an intrathecal lower lumbar T1/short tau inversion recovery (STIR) signal, fluid-fluid level, and cauda equina enhancement suggestive of a subarachnoid hemorrhage, as well as a well-circumscribed, compressive T2-T3 subdural collection consistent with hematoma, later confirmed by pathology. Notably, bleeding occurred in the absence of coagulopathy or dural puncture. A spinal angiogram ruled out vascular lesions. The patient underwent a successful laminectomy and intradural hematoma evacuation, resulting in gradual functional recovery.

To our knowledge, this is the first reported case of SSDH following uncomplicated SCS. Possible etiology includes epidural trauma from SCS lead placement, causing shear stress, leading to an angiogenic/inflammatory response with eventual neomembrane formation and space-occupying hematoma responsible for the subacute myelopathic presentation. Prompt diagnosis and treatment are crucial to prevent permanent neurological damage due to spinal compression.