Response to “Spontaneous acute epidural haematoma of the cervical spine with an atypical onset resembling ictal symptom”

Dear Editor:

We read with great interest the letter to the editor by Arévalo et al.¹ entitled “Spontaneous acute epidural haematoma of the cervical spine with an atypical onset resembling ictal symptom.” We would like to thank the authors for the valuable clarifications on the management of these patients. Most of the conclusions and information on this type of disease are from a small number of case reports with an inherent selection bias, or small series that lack detailed statistical analysis. However, we would like to clarify some points based on our experience and on the only Spanish multicentre study, conducted by members of our working group, which included 29 patients with surgically treated spontaneous epidural spinal haematoma.²

We agree with Arévalo et al.¹ that treatment of this type of lesions is essentially surgical. Furthermore, in patients presenting spontaneous improvement or whose health condition contraindicates surgery, a conservative approach should be adopted. Spontaneous improvement is more frequent than we may expect³; in our series, we excluded 2 patients who presented excellent progression, eventually recovering, despite not having received surgical treatment. The usefulness of corticosteroids in patients ineligible for surgical treatment has not been clearly demonstrated in the case of spinal haematoma⁴; all the available conclusions and recommendations are from the NACIS multicentre study.⁵

Our study on prognostic factors in patients with surgically treated spontaneous spinal haematomas² showed that late surgery was associated with poor prognosis and absence of neurological improvement. However, up to 43% of the patients undergoing surgery in the first 24 hours showed some degree of objective neurological improvement. Likewise, contrary to the results of studies into spinal cord trauma,⁶ the degree of neurological involvement before surgery was not significantly associated with prognosis. In view of these 2 findings, we may conclude that although neurological recovery is multifactorial, surgical decompression is a relatively safe technique that should be performed as early as possible in patients with neurological involvement. However, persistence of symptoms beyond 24 hours or presence of complete spinal cord lesion should not be considered contraindications for surgical treatment in patients with compression due to spinal haematoma.

The study by Arévalo et al.¹ introduces several elements into the description of the radiological image that, despite being interesting from a descriptive point of view, are of little prognostic value. The most relevant radiological images include an increased length of the intra-axial lesion shown by an increased intra-axial signal in T2-weighted sagittal MRI sequences of the spinal cord, which is the only radiological prognostic factor found to date.² The length of the extra-axial haematoma and the percentage of occupation of the spinal canal are not as relevant as the latter radiological finding. The benefit of having radiological variables that may help predict prognosis with some degree of certainty becomes especially relevant in circumstances in which proper neurological examination is not possible: patients under sedation or who are uncooperative.⁶ We should mention that the extension of the lesion is a time-dependent variable: it is thought to increase in length by approximately 10 mm per day.⁷ Therefore, the prognostic value of MRI becomes significant when it is performed in the first 48-72 hours after symptom onset.⁸ Arévalo et al.¹ report that the patient was surgically treated after diagnosis by CT scan and that MRI was performed after the procedure. It would be interesting to analyse the motives leading to that decision.

Based on the above, we recommend performing a spinal MRI scan and prescribing surgical treatment as early as possible in patients with spinal cord compression. Creation of a radiological protocol including sagittal T2-weighted sequences as the main diagnostic study would help to save time in the management of these patients, who require urgent treatment. Adding the length of the intramedullary lesion to the radiological description would provide a better idea of recovery expectations in these patients. In those cases in which performing an MRI scan would delay surgical treatment beyond 48 hours, it would be appropriate to prioritise emergency surgical treatment over the prognostic value of MRI.

Funding

This study has received no external funding.