Cervical spinal epidural haematoma: the double jeopardy

Spontaneous spinal epidural haematoma is an unusual but well recognized cause of compressive myelopathy or cauda equina syndrome. Radicular pain is one of the earliest symptoms and a hallmark of spontaneous spinal epidural haematoma, as in the case of cervical spondylosis and disc prolapse. Should an epidural haematoma be located in the cervical spine, the resultant cervical radicular pain may sometimes be erroneously attributed to a cardiac cause, especially in the setting of pre-existing cardiac disease. The error in diagnosis can lead to another pitfall, the addition of heparin. If the etiology of the pain is a cervical epidural haematoma this can have grave consequences. Moreover, patients with cardiac ischemia who are treated with anticoagulants may rarely develop a cervical epidural haematoma. The resulting radicular pain can overlap with cardiac pain and escape recognition. Symptoms of neck and upper extremity pain with bilateral signs of myelopathy with a sensory level should lead to a suspicion of acute cervical cord compression. The addition of heparin can only compound the disastrous consequence of a rapidly expanding spinal epidural haematoma. The following cases illustrate this diagnostic and therapeutic conundrum.