Does different operation timing for spontaneous cervical spinal epidural hematoma lead to different prognosis? A retrospective study of 36 cases

Does different operation timing for spontaneous cervical spinal epidural hematoma lead to different prognosis? 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A retrospective study of 36 cases Kaiqi Mo, Guanlu Peng, Huisheng Lu, Chengqiang Yu, Xiaoping Mu, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8262636/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background SCSEH ( Spontaneous cervical spinal epidural hematoma) is a rare yet serious clinical entity characterized by idiopathic, non-traumatic, and non-iatrogenic accumulation of blood in the cervical epidural space. For patients who experience sudden neck pain and nerve root pain symptoms, acute cervical spinal epidural hematoma should be regarded as a possible differential diagnosis cas.In recent years, such cases have been reported globally, yet treatment strategies remain heterogeneous with inconclusive efficacy evidence. While surgical decompression is widely advocated for optimal neurological recovery, conventional protocols lack specificity regarding optimal intervention timing.Over a 13-year period, we surgically managed 36 SCSEH cases. This study analyzes the intervals from symptom onset to hospital admission and admission to surgical intervention, with comparative assessment of postoperative neurological outcomes. Methods A retrospective study was conducted on 36 patients (23 males and 13 females; mean age 48.43 ± 2.17 years) diagnosed with SSCEH between January 2006 and January 2019. All patients presented with varying degrees of neurological deficits upon admission and underwent single-stage surgical intervention comprising cervical spinal canal decompression, epidural hematoma evacuation, and internal fixation. Patients were categorized based on the time interval from symptom onset to surgery.Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) score, Visual Analog Scale (VAS), and American Spinal Injury Association (ASIA) Impairment Scale. All patients achieved a minimum follow-up of 12 months (mean 16.4 ± 2.17 months). Radiographs, CT(computed tomography ), and MRI(magnetic resonance imaging ) were utilized to evaluate fusion status and spinal stability. Results All 36 patients exhibited statistically significant improvements (P < 0.05) in ASIA grade, VAS score, and JOA score at the final follow-up compared to preoperative assessments. Functional recovery was comparable between patients undergoing surgery within 8 hours of symptom onset and those operated between 8 and 24 hours post-onset, with no statistically significant difference in postoperative functional outcomes (p > 0.05). However, patients receiving surgical intervention within 24 hours demonstrated significantly superior functional recovery compared to those operated beyond 24 hours (P < 0.05). The postoperative follow-up imaging results indicated no rebleeding, no significant loss of cervical curvature, no collapse of the bone graft or no displacement of the implant, and good spinal canal volume. Conclusions Patients with SCSEH undergoing surgery within 8 hours of symptom onset demonstrated comparable postoperative functional recovery to those operated between 8–24 hours. However, subjects receiving intervention within 24 hours collectively showed superior functional outcomes compared to those undergoing surgery beyond 24 hours Trial registration: The studies involving humans were approved by the Ethics Committee of People's Hospital of Guangxi Zhuang Autonomous Regionl. The studies were conducted in accordance with the local legislation and institutional require ments. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements. cervical spine spinal epidural hematoma surgery timing MRI Figures Figure 1 Figure 2 Figure 3 Background Spontaneous cervical intraspinal epidural hematoma was first proposed by Jackson R. in 1869 [ 1 ]. These patients often have vascular malformations, anticoagulation and thrombolysis, abnormal coagulation or platelet function, hemophilia, Paget's disease, leukemia, pregnancy, hypertension, minor trauma, increased abdominal pressure, etc. About 1/3 of these patients are undergoing anticoagulation therapy[ 2 ]. Clinically, it is also necessary to make differential diagnosis from epidural abscess, cervical tuberculosis, metastatic tumor, lymphoma, schwannoma, meningioma and cavernous hemangioma[ 3 ], and it is not difficult to make a preliminary diagnosis based on the patient's previous disease history, medication and pathogenesis. Spontaneous cervical intraspinal epidural hematoma is a relatively rare clinical disease with insidiousonset and rapid development, characterized by progressive and aggravated neurological dysfunction, with an incidence of about 0.1/100,000[ 4 ], accounting for 0.3% to 0.9% of space occupying lesions in the spinal canal. The incidence of male is slightly higher than that of female (1.4:1)[ 5 ]. Clinically, these diseases are generally divided into idiopathic spinal epidural hematoma, spontaneous spinal epidural hematoma and recurrent spinal epidural hematoma. About one-third of spinal epidural hematomas with no clear cause are called idiopathic spinal epidural hematomas. At the same time according to the time of onset can be divided into acute or chronic. Traumatic spinal epidural hematoma can turn into chronic pain for months or years. Sometimes epidural vascular malformation can occur. Factors such as coughing, sneezing, urinating, lifting weights, and even playing the trumpet can increase the pressure and may cause bleeding due to a ruptured vein. Therapeutic outcome depends on the delay between symptom onset and accurate diagnosis and between diagnosis and surgical decompres sion; thus, management remains a challenge for physicians[ 6 ]. Its early suspicion is of paramount importance, allowing an accurate diagnosis and emergent surgical therapy when needed. MRI is the gold standard to set this diagnosis and rule out other mimicking conditions[ 7 ]. Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits[ 8 , 9 ] Chronic pain is a common symptom during the follow-up period after SSEH surgery. Timely intervention can lead to satisfactory results[ 10 ]. 1 Methods 1.1 Materials and methods Our institutional ethics review board approved this retrospective study, which reviews patient imaging images and medical records without patient approval or informed consent. A retrospective study was conducted on 36 patients (23 males and 13 females; mean age 48.43 ± 2.17 years) diagnosed with SSCEH between January 2006 and January 2019. The mean age was 48.43 ± 2.17 years. On admission, all 36 patients had spinal cord and nerve root compression, neck and shoulder pain with incomplete limb paralysis (ASIA grade, 5 cases A grade, 18 cases B grade, 9 cases C grade, 4 cases D grade), 19 cases had different degrees of upper extremity root pain. The average preoperative VAS score was 5.27 ± 2.14. The JOA score averaged (8.78 ± 1.42) points. All patients did not have elevated body temperature, and the counts of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white blood cells (WBC) were within the normal range. Preoperative CT and MRI examinations of the cervical spine showed epidural hematoma formation in all patients. There were 14 cases with double segments, including 6 cases with C4 and C5, 6 cases with C5 and C6, and 2 cases with C6 and C7. There were 22 cases in 3 segments, 10 cases in C3-C5, 9 cases in C4-6, and 3 cases in C5-7. There were 12 patients operated within 8 hours, 15 patients operated within 8–24 hours, and 9 patients operated longer than 24 hours. Twenty-three patients were diagnosed with hypertension, 26 with BMI greater than 30,8 with type 2 diabetes, and 4 with long-term anti-platelet aggregation therapy. Hematoma occurred in the ventral side of the spinal cord in 3 cases and in the dorsal side of the spinal cord in 33 cases. Exclusion criteria: 1. Spinal nonspecific infection. 2. Tuberculosis of the spine. 3. Cervical cancer. 4. Cervical spine fracture and dislocation. 5. Cervical spine injury without fracture and dislocation. 6. History of cervical spine surgery. 7. Hemophilia. 1.2 Surgery and treatment In order to save the spinal cord function as soon as possible, all patients were treated with stage I emergency surgery. All patients underwent endotracheal intubation under general anesthesia after improving preoperative preparation. Depending on the location of the hematoma we give the patient different positions and surgical procedures, if the hematoma is ventral to the spinal cord we usually do anterior cervical vertebrae resection and fusion, and the patient is placed in a supine position. If the hematoma is on the dorsal side of the spinal cord we usually use a posterior cervical hemilaminectomy decompression and fusion. In the anterior cervical vertebrae resection and fusion surgery, the target vertebra was first positioned under the C-arm X-ray machine, the right transverse incision of the neck was performed (Smith-Robinson approach), the cervical vascular sheath and tracheoesophageal sheath space were bluntly separated into the prevertebral fascia, the target vertebra and disc were exposed, and the Caspar vertebral retractor was installed between the upper and lower normal vertebrae. The intervertebral disc and vertebral tissue of the affected segment were removed to the posterior longitudinal ligament. Black coagulation hematoma was found behind the posterior longitudinal ligament in both cases. After repeated rinsing with 0.9% sodium chloride saline, possible bleeding points and ruptured venous plexus in the surrounding tissue were thoroughly examined, and the length of the spinal defect was measured. A titanium mesh containing the excised vertebral bone tissue was placed in the vertebral bone trough, an intervertebral spinner was removed, a titanium plate of appropriate length was installed, and a drainage tube was placed in the incision and the incision was closed. After posterior cervical semi-laminectomy decompression fusion surgery, the target vertebra was first located under the C-arm X-ray machine, the median posterior cervical incision was made, the spinous process of the target segment and bilateral laminae were exposed, the needle insertion point and Angle were determined according to Magerl technique, lateral mass screws were placed on both sides of the segment scheduled for decompression, and the C-arm X-ray machine fluoroscopy confirmed the good position of the screws. Titanium rods of appropriate length were selected and precurved, and the precurved rods were inserted and fixed with nuts to restore the physiological lordosis of the cervical spine as much as possible. The laminae on the side of the hematomas pressing in the fixed segment were removed with a grinding drill and a bone rongeur. Black coagulated hematomas could be seen after the ligamenta flandum was removed. After repeated rinses with 0.9% sodium chloride saline were used to remove the hematomas, possible hemorrhagic points in the surrounding tissues and ruptured venous plexus were thoroughly examined (see Fig. 1), and the hemorrhagic points were coagulated with bipolar electrocoagulation. Bone fragments implanted in the contralateral laminae were polished by grinding and drilling, and bone fusion was performed. Place a drainage tube inside the incision and close the incision. All patients were immediately fixed with neck girth after surgery, drainage was removed after the drainage volume was less than 30ml for 24 ~ 48h, and rehabilitation activities were performed after 48h in bed with neck sitting around and/or getting up. Neck girth was fixed for 4 weeks after surgery. 1.3 Follow-up The position of cervical implant fixation and cervical curvature were evaluated by routine postoperative radiographs. All patients were followed up for 1, 3, 6, 12, and 18 months. Radiographs were used to determine the location of postoperative fixation and possible faults, CT scans were performed to understand the bony spinal canal, and MR Examinations were performed every 12 months to understand the spinal cord (see Fig. 3). Function was evaluated clinically by ASIA scale, JOA and VAS. 1.4 Statistical method SPSS 18.0 (SPSS, USA) statistical software was used for analysis. Measurement data were expressed as x ± s and one-way analysis of variance was used Differences at different time points were compared, or paired T-test was used to compare preoperative and postoperative indicators. Counting data were tested by chi-square test. P < 0.05 was considered statistically significant. 2 Results 2.1 Statistical result All patients in this group successfully completed the operation and were followed up for 12 to 36 months (mean 16.4 ± 2.17 months). All patients achieved grade ASIA remission within 1 week after surgery. Of the 23 patients with neurological impairment, 18 of them recovered to grade E in ASIA one month after surgery (Table 1 ). The VAS scores at 7 days and 3 months after surgery showed a decrease in compliance, with the average preoperative score (7.29 ± 1.35) and the average postoperative score at 3 months (2.59 ± 1.44) (P < 0.05). The average preoperative JOA score was (8.38 ± 2.22) and (12.42 ± 1.66) three months after surgery (P < 0.05) (Table 2 , 3 ). Among them, the functional recovery of patients operated within 8 hours of the onset of surgery was similar to that of patients operated within 8–24 hours of the onset of surgery, and there was no statistical significance in the functional evaluation of postoperative JOA and VAS scores (p > 0.05). The functional recovery of patients operated within 24 hours was better than that of patients operated after 24 hours. The functional evaluation of JOA and VAS scores after surgery had statistical significance (P < 0.05) (Table 2 , 3 ). No postoperative infection or vascular injury occurred in all patients until the last follow-up. Postoperative pulmonary infection occurred in 2 cases, which recovered after treatment with nebulization and sensitive antibiotics. No rebleeding was found in all patients at the last follow-up, the spinal canal volume was good, bone grafting was completely healed, and no internal fixation loosening or cervical kyphosis occurred. Table 1 ASIA grades of the patients preoperatively and during the follow-ups after the operation (n = cases) Grade 7 Days After the Postoperative Preoperative Grade Number of Cases A B C D E The Last Follow-up A 5 2 0 0 0 0 0 B 18 0 7 0 0 0 2 C 9 0 0 18 0 0 2 D E Total 4 0 36 0 0 0 0 2 7 0 7 0 0 18 7 0 2 2 4 18 36 Table 2 VAS scores for comparison (x ± s) VASScore Number of Cases Before the Operation 1 Week After the Operation 3 Months After the Operation 6 Months After the Operation 12 Months After the Operation The Last Follow-up P Value 24h 12 15 9 7.35 ± 1.57 7.58 ± 1.13 6.95 ± 1.36 3.47 ± 2.46 3.61 ± 1.95 3.23 ± 1.35 2.43 ± 1.29 2.77 ± 1.35 2.58 ± 1.67 1.79 ± 1.67 1.75 ± 1.24 1.82 ± 1.54 1.48 ± 1.81 1.82 ± 1.19 1.62 ± 1.43 1.59 ± 1.52 1.67 ± 1.44 1.75 ± 1.28 0.028 0.022 0.031 Note: p < 0.05 means that the difference is statistically significant. Table 3 JOA scores for comparison (x ± s) JOAScore Number of Cases Before the Operation 1 Week After the Operation 3 Months After the Operation 6 Months After the Operation 12 Months After the Operation The Last Follow-up 8h PValue 12 15 9 8.21 ± 2.76 8.35 ± 1.68 8.58 ± 2.21 0.183 10.27 ± 2.47 10.05 ± 1.87 9.87 ± 2.47 0.076 13.36 ± 1.35 12.57 ± 2.03 11.34 ± 1.59 0.031 13.34 ± 1.52 13.03 ± 2.15 12.28 ± 1.97 0.045 13.83 ± 2.25 13.15 ± 1.3412.54 ± 1.61 0.042 14.80 ± 1.84 14.06 ± 2.25 12.14 ± 1.38 0.028 Note: p < 0.05 means that the difference is statistically significant. 2.2 Typical cases (Figs. 1, 2, 3) 3 Discussion 3.1 Clinical characteristics Acute intraspinal epidural hematoma was first reported by Jackson R. Case of spinal apoplexy in the Lancet in 1869 [J]. Lancet, 1896, 94(2392): 5–6. Alexiadou-Rudolf C et al. calculated that spontaneous cervical epidural hematoma accounted for 0.3% to 0.9% of epidural lesions [ 1 ]. 1. Alexiadou-Rudolf C, Ernestus RI, Nanassis K, et al. Acute nontraumatic spinal epidural hematoma. An important differential diagnosis in spinal emergencies[J]. Spine, 1998, 23(16):1810–1813. Spontaneous hemorrhage in the spinal canal is more common in adults, but it can occur at any age. The age distribution in this group was 35–68 years old, with an average age of 42.7 years. Similar to reports by Shin JJ et al. [ 2 ] Shin JJ, Kuh SU, Cho YE, et al. Surgical management of spontaneous spinal epidural hematoma [J]. Eur Spine,2006, 15(6):998–1004. Clinical mainly acute onset, sudden onset, there are intracranial and thoracoabdominal pressure suddenly increased induction factors, such as labor, jumping, defecation, emotional excitement, laughter and sneezing. At the same time, acute pain in the neck and its innervation area corresponding to the involvement of the hematoma may occur in a short time, sensory and motor dysfunction below the injury plane, and even complete paralysis (delayed paralysis with reduced reflexes is more common). The main symptoms of the patients were bilateral nerve function deficit in the diseased segment. For patients who experience sudden neck pain and nerve root pain symptoms, acute cervical spinal epidural hematoma should be regarded as a possible differential diagnosis case[ 11 ]. 3.2 Pathological feature Hentschel et al. [ 5 ] believed that rupture of epidural venous plexus, rupture of malformed blood vessels and rupture of epidural artery were the main causes of hematoma. Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases[J]. Spine, 2001, 26(22): E525-E527. Meanwhile, most of the patients in this group have a history of hypertension for many years, and its mechanism may be similar to that of hypertension causing strok[ 12 ]. At the same time, we found that most patients also had type 2 diabetes. We believe that long-term hypertension and diabetes may lead to vascular lesions in the spinal canal, increased brittleness, and easy to rupture during acute pressure changes. On imaging, hematoma is usually located on the dorsal side of the spinal cord, which is closely connected with the ventral venous plexus of the spinal cord and the posterior longitudinal ligament, and the lacuna is small and dense. The dorsal epidural of the spinal canal is mostly composed of adipoid tissue with sparse structure and rich venous plexus. [ 3 ] Groen RJ. Non -operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases [J]. Acta Neurochir (Wien), 2004,146(2): 103–110. However, hematoma occurred in the ventral side of the spinal cord in two patients in this group, and it cannot be ruled out that these two patients were caused by arterial malformation rupture. 3.3 Imaging performance MRI plain scan plus enhanced examination is an important method for definitive diagnosis, and it is also the gold standard for clinical diagnosis. All patients reviewed in our hospital showed signs of epidural hematoma on MRI. The signal changes of MRI were mainly related to the bleeding time, especially the characteristic changes of T2WI: hyperacute stage (< 24h) : T1WI signal level, T2WI high signal; Acute phase (1 ~ 3d) : T1WI signal, T2WI low signal; Early subacute stage (3 ~ 7 days) : T1WI high signal, T2WI low signal; In the late subacute stage (7–14 days), both T1WI and T2WI showed high signal. Chronic phase (> 14 days) : High signal on T1WI and T2WI. In chronic phase, enhanced MRI scan can show banding enhancement around hematoma. MRI is also an important test to distinguish acute epidural hematoma from other epidural lesions such as epidural abscess, epidural angiolipoma, cavernous hemangioma, metastasis, lymphoma, etc. In other tests, if the cause of bleeding is a cavernous hemangioma, DSA often shows no positive findings, or only an uncharacterized lack of vascular lesions. MRI showed local myelocele with mixed signals in the tumor. From the clinical standpoint, it is paramount that suspected SSEH patients undergo the proper screening in a timely fashion. MRI showing T2 hyperintensity within the spinal cord within 24 h is a poor prognostic indicator[ 13 ]. In a study involving 20 patients with SEH, Chang et al[ 14 ] reported that most of the hematomas examined within 36 hours after the onset of symptoms showed uniform and equal signals on T1-weighted images compared to the spinal cord, and uniform high signals on T2-weighted images. However, in magnetic resonance imaging conducted more than 36 hours after the onset of symptoms, it was found that some hematomas showed uneven equal signals or high signals on T1-weighted images, and mixed high and low signal changes on T2-weighted images. For the assessment of the severity of neurological function in acute SSEH, traditionally, the ASIA classification was relied upon. However, the value of imaging indicators has gradually gained attention. Honda et al. conducted a multicenter study that filled this gap - by analyzing the T2-weighted MRI images of 57 patients, they first clearly identified that the low-signal layer around the hematoma (pathologically confirmed as the collagen capsule), the uneven signal within the hematoma (indicating continuous bleeding), and the spinal canal occupancy rate (COR) > 40% were independent imaging markers for predicting severe paralysis. This provided a quantitative basis for clinicians to quickly determine the severity of the condition through MRI[ 15 ]. 3.4 Treatment As the treatment of the disease, the literature content is varied, generally divided into two ways: 1. Conservative treatment, 2 surgical treatment. Since Priest first reported on conservative treatment of SSEH in 1935, some scholars have reported cases of conservative treatment of SSEH, some of which have achieved satisfactory result[ 3 , 8 , 16 – 18 ]. 3. Groen RJ. Non -operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases [J]. Acta Neurochir (Wien), 2004,146(2): 103–110. 4. Duffill J, Sparrow OC, Millar J, et al. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases[J]. J Neurol Neurosurg Psychiatry, 2000, 69(6): 816–819. They considered that conservative treatment should be attempted in the following cases: (1) patients with mild neurological impairment with an AISA or Frankel grade of E; (2) Patients with an AISA or Frankel grade of C/D, but with gradual recovery of neurological function; (3) Early recovery of neurological function after onset, and progressive improvement; (4) Patients with obvious surgical contraindications. After the onset of SSEH, neurological function improvement and hematoma absorption can be seen in some patients at an early stage, and the possible mechanisms are "hematoma diffusion" and "hematoma leakage";(5) Cases of spontaneous epidural hematoma with mild symptoms or those showing improvement [ 3 , 5 ]. 5. Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: reportof two cases[J]. Spine, 2001, 26(22): E525-E527. The former means that the hematoma spreads along the epidural space and thus "decompresses itself," while the latter means that the hematoma can partially leak out of the foramina, thereby reducing intravertebral pressure and reducing spinal cord and nerve compression. Conservative treatment is subject to many limitations, such as the judgment of neurological function, the progression of the patient's symptoms, and the judgment of blood volume, etc., such as the judgment error will delay the treatment time of the patient. At the same time, many conservatively treated patients have a legacy of chronic pain in the dominant area of the responsible segment, and loss of motor and sensory function. During conservative treatment, the interruption of anticoagulant therapy is not always necessary,especially when the clinical symptoms improve on their ow[ 19 ]. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested[ 20 ]. Conservative treatment could not prevent occurrence of multiple episodes or rebleeding in patients. Microsurgery should be recommended as the preferred treatment strategy for SSEH[ 20 ]. At present, most scholars advocate early decompression of spinal canal and removal of hematoma in order to recover nerve function as soon as possible. Based on our reported cases and literature review, we believe that stage I surgical decompression has the highest benefit rate for patients. Hussenbocus SM, Wilby MJ, Cain C, et al. Spontaneous spinal epidural hematoma: a case report and literature review[J]. Emerg Med, 2012, 42(2): e31-34. Liao CC, Hsieh PC, Lin TK, et al. Surgical treatment of spontaneous spinal epidural hematoma: a 5-year experience[J]. Neurosurg Spine, 2009, 11(4): 480–486. (in Chinese) Although some patients have a certain effect of conservative treatment, the long cycle of conservative treatment and the prolonged bed rest of patients increase the incidence of complications, the length of hospital stay and the hospitalization cost of the whole treatment cycle. Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits[ 21 ]. Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention[ 22 ]. Prompt surgical evacuation of the hematoma leadsto afavorable neurological outcome, whereas delay in treatment can bedisastrou[ 23 ]. Significant neurological recovery after surgical decompression of SSEHs can be achieved, despite[ 24 ]. Even in cases where CT scan is negative, the working diagnosis should be hemorrhage with cord compression, and spine MRI should be urgently performed. Once a diagnosis is achieved, we recommend urgent surgical decompression of the spinal cord[ 25 ]. Prompt surgical decompression is valuable, irrespective of the time interval between symptom onset and operation in infant[ 26 ]. the significant preoperative neurological deficits, spinal cord changes on MRI, and delayed timing of intervention. At the same time, the absorption rate of hematoma is slow, and the patient's spinal cord will be compressed for a long time, which will lead to the limited recovery of nerve function, and eventually lose the recovery opportunity. Even if some patients do not have further neurological function, some neurological function loss remains. In the cases we reviewed, Stage I surgical decompression was shown, and all patients achieved good neurological function improvement at 7 days after surgery. The two groups of patients who underwent decompression within 24 hours after the onset of the disease had similar neurological function benefits. The main reason was that this type of epidural hematoma was mostly caused by venous rupture and bleeding. The low venous pressure limited the amount of blood loss within the relatively limited space of the spinal canal, and the amount of blood loss decreased with the increase of the pressure in the spinal canal, and the process of pressure induction was slow, limiting the further loss of nerve function. This is the opposite mechanism of acute traumatic spinal cord injury. However, when the bleeding time is prolonged and the hematoma reaches the maximum value, the spinal cord function is correspondingly damaged to the greatest extent. Even though the hematoma may have a small volume of self-absorption, the damage is irreparable. 4 Conclusions Although some cases have been reported in which patients recovered after conservative treatment, our study shows that surgical intervention is clearly relevant in this population of patients with acute intramural hemorrhage, regardless of neurological impairment. The review showed that decompression surgery was completed within 24 hours of the onset of the disease, the prognosis of the patients was significantly improved, and the patients who had more than 24 hours had to undergo decompression surgery, although the recovery of neurological function may be limited, but the further deterioration of neurological function was prevented. 5 Restrict The study has several limitations, most notably its retrospective nature. The lack of direct case controls, particularly those related to clinical outcomes in non-surgical patients, makes it impossible to directly compare the efficacy of surgical versus non-surgical interventions in patients with acute intraspinal hemorrhage. Limitations also include the small sample size of patients included in our study, which was insufficient for statistical analysis of univariate and multivariate variables and the estimation of the corresponding influence size, and limited the statistical ability to analyze the risk factors of preoperative and postoperative complications. Ethical approval and consent to participate This study involving human participants and human data was conducted in full compliance with the ethical principles outlined in the World Medical Association (WMA) Declaration of Helsinki The protocol was reviewed and approved by the Ethics Committee of the People's Hospital of Guangxi Zhuang Autonomous Region (KY-IIT-2020-02). All procedures were performed in accordance with local legislation, institutional requirements, and the core tenets of the Declaration of Helsinki, including principles related to the protection of participants’ health, dignity, autonomy, privacy, and confidentiality of personal information. In accordance with national legislation and institutional requirements for retrospective studies of this nature, written informed consent from participants or their legal guardians/next of kin was not required, as the research involved the anonymized review of existing medical records and imaging data without direct interaction with participants. This exemption was approved by the aforementioned Ethics Committee and is consistent with the Declaration of Helsinki’s provisions for minimizing unnecessary burdens on participants when research poses minimal risk and cannot be feasibly conducted otherwise. All efforts were made to ensure that the rights and welfare of participants were safeguarded throughout the study, and the potential benefits of the research (advancing understanding of optimal surgical timing for SCSEH) outweighed any minimal risks associated with retrospective data analysis. Declarations Competing interests The authors declare that they have no competing interests. Funding This research was supported by the Guangxi Natural Science Foundation (Project Number: 2023GXNSFAA02628523) and was awarded to Dr. Haoxi Li. Author Contribution Please use initials to refer to each author's contribution in this section, for example: "FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript." Acknowledgments Not applicable Clinical Trial Number Not applicable Consent for Publication Not applicable Data Availability The raw data supporting the findings of this study are not publicly available. This restriction is primarily due to the fact that the data contain sensitive personal health information (PHI) of participants, including detailed medical records, imaging data, and clinical assessment results. Disclosure of such information could compromise the privacy and confidentiality of individual participants, which is strictly protected in accordance with national data protection regulations, institutional ethical guidelines, and the principles of the Declaration of Helsinki.Additionally, the data are part of the institutional medical record system, and access is restricted to authorized personnel for clinical and research purposes only. While we recognize the value of data sharing for scientific advancement, we prioritize the protection of participants’ rights and welfare. 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Villas C, Silva A, Alfonso M. Pure cervical radiculopathy due to spontaneous spinal epidural haematoma (SSEH): report of a case solved conservatively. Eur Spine J. 2006;15(S5):569–73. Yu J, et al. Spontaneous Spinal Epidural Hematoma: A Study of 55 Cases Focused on the Etiology and Treatment Strategy. World Neurosurg. 2017;98:546–54. Lenga P, et al. Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications. Acta Neurochir. 2023;165(4):905–13. Chan DTM, et al. Spinal shock in spontaneous cervical spinal epidural haematoma. Acta Neurochir. 2004;146(10):1161–3. Gopalkrishnan CV, Dhakoji A, Nair S. Spontaneous cervical epidural hematoma of idiopathic etiology: Case report and review of literature. J Spinal Cord Med. 2013;35(2):113–7. Baeesa S, et al. Spontaneous Spinal Epidural Hematoma: Correlation of Timing of Surgical Decompression and MRI Findings with Functional Neurological Outcome. World Neurosurg. 2019;122:e241–7. Rajz G, et al. Spontaneous spinal epidural hematoma: The importance of preoperative neurological status and rapid intervention. J Clin Neurosci. 2015;22(1):123–8. Lee J, et al. Spontaneous spinal epidural hematoma in a 4-month-old infant. Spinal Cord. 2007;45(8):586–90. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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2","display":"","copyAsset":false,"role":"figure","size":272699,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8262636/v1/276c8681b7ea6d8e71caacb3.jpeg"},{"id":100690992,"identity":"876dfb7f-0bf3-4ede-9ee3-fc269673669d","added_by":"auto","created_at":"2026-01-20 14:01:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":547671,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8262636/v1/46531453b990cd5aa89ea192.png"},{"id":107412274,"identity":"637d3bd5-2317-4569-bec6-3bba735d9c91","added_by":"auto","created_at":"2026-04-21 09:13:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1698953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8262636/v1/293dbbb3-b3e5-4ea7-a53a-51e0147ccc0e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does different operation timing for spontaneous cervical spinal epidural hematoma lead to different prognosis? A retrospective study of 36 cases","fulltext":[{"header":"Background","content":"\u003cp\u003eSpontaneous cervical intraspinal epidural hematoma was first proposed by Jackson R. in 1869 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These patients often have vascular malformations, anticoagulation and thrombolysis, abnormal coagulation or platelet function, hemophilia, Paget's disease, leukemia, pregnancy, hypertension, minor trauma, increased abdominal pressure, etc. About 1/3 of these patients are undergoing anticoagulation therapy[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinically, it is also necessary to make differential diagnosis from epidural abscess, cervical tuberculosis, metastatic tumor, lymphoma, schwannoma, meningioma and cavernous hemangioma[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and it is not difficult to make a preliminary diagnosis based on the patient's previous disease history, medication and pathogenesis. Spontaneous cervical intraspinal epidural hematoma is a relatively rare clinical disease with insidiousonset and rapid development, characterized by progressive and aggravated neurological dysfunction, with an incidence of about 0.1/100,000[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], accounting for 0.3% to 0.9% of space occupying lesions in the spinal canal. The incidence of male is slightly higher than that of female (1.4:1)[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Clinically, these diseases are generally divided into idiopathic spinal epidural hematoma, spontaneous spinal epidural hematoma and recurrent spinal epidural hematoma. About one-third of spinal epidural hematomas with no clear cause are called idiopathic spinal epidural hematomas. At the same time according to the time of onset can be divided into acute or chronic. Traumatic spinal epidural hematoma can turn into chronic pain for months or years. Sometimes epidural vascular malformation can occur. Factors such as coughing, sneezing, urinating, lifting weights, and even playing the trumpet can increase the pressure and may cause bleeding due to a ruptured vein. Therapeutic outcome depends on the delay between symptom onset and accurate diagnosis and between diagnosis and surgical decompres sion; thus, management remains a challenge for physicians[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Its early suspicion is of paramount importance, allowing an accurate diagnosis and emergent surgical therapy when needed. MRI is the gold standard to set this diagnosis and rule out other mimicking conditions[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early MRI and prompt neurosurgical intervention are also important to improve the neurological deficits[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Chronic pain is a common symptom during the follow-up period after SSEH surgery. Timely intervention can lead to satisfactory results[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"1 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Materials and methods\u003c/h2\u003e \u003cp\u003eOur institutional ethics review board approved this retrospective study, which reviews patient imaging images and medical records without patient approval or informed consent. A retrospective study was conducted on 36 patients (23 males and 13 females; mean age 48.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 years) diagnosed with SSCEH between January 2006 and January 2019. The mean age was 48.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 years. On admission, all 36 patients had spinal cord and nerve root compression, neck and shoulder pain with incomplete limb paralysis (ASIA grade, 5 cases A grade, 18 cases B grade, 9 cases C grade, 4 cases D grade), 19 cases had different degrees of upper extremity root pain. The average preoperative VAS score was 5.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14. The JOA score averaged (8.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42) points. All patients did not have elevated body temperature, and the counts of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and white blood cells (WBC) were within the normal range. Preoperative CT and MRI examinations of the cervical spine showed epidural hematoma formation in all patients. There were 14 cases with double segments, including 6 cases with C4 and C5, 6 cases with C5 and C6, and 2 cases with C6 and C7. There were 22 cases in 3 segments, 10 cases in C3-C5, 9 cases in C4-6, and 3 cases in C5-7. There were 12 patients operated within 8 hours, 15 patients operated within 8\u0026ndash;24 hours, and 9 patients operated longer than 24 hours. Twenty-three patients were diagnosed with hypertension, 26 with BMI greater than 30,8 with type 2 diabetes, and 4 with long-term anti-platelet aggregation therapy. Hematoma occurred in the ventral side of the spinal cord in 3 cases and in the dorsal side of the spinal cord in 33 cases.\u003c/p\u003e \u003cp\u003eExclusion criteria: 1. Spinal nonspecific infection. 2. Tuberculosis of the spine. 3. Cervical cancer. 4. Cervical spine fracture and dislocation. 5. Cervical spine injury without fracture and dislocation. 6. History of cervical spine surgery. 7. Hemophilia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Surgery and treatment\u003c/h2\u003e \u003cp\u003eIn order to save the spinal cord function as soon as possible, all patients were treated with stage I emergency surgery. All patients underwent endotracheal intubation under general anesthesia after improving preoperative preparation. Depending on the location of the hematoma we give the patient different positions and surgical procedures, if the hematoma is ventral to the spinal cord we usually do anterior cervical vertebrae resection and fusion, and the patient is placed in a supine position. If the hematoma is on the dorsal side of the spinal cord we usually use a posterior cervical hemilaminectomy decompression and fusion.\u003c/p\u003e \u003cp\u003eIn the anterior cervical vertebrae resection and fusion surgery, the target vertebra was first positioned under the C-arm X-ray machine, the right transverse incision of the neck was performed (Smith-Robinson approach), the cervical vascular sheath and tracheoesophageal sheath space were bluntly separated into the prevertebral fascia, the target vertebra and disc were exposed, and the Caspar vertebral retractor was installed between the upper and lower normal vertebrae. The intervertebral disc and vertebral tissue of the affected segment were removed to the posterior longitudinal ligament. Black coagulation hematoma was found behind the posterior longitudinal ligament in both cases. After repeated rinsing with 0.9% sodium chloride saline, possible bleeding points and ruptured venous plexus in the surrounding tissue were thoroughly examined, and the length of the spinal defect was measured. A titanium mesh containing the excised vertebral bone tissue was placed in the vertebral bone trough, an intervertebral spinner was removed, a titanium plate of appropriate length was installed, and a drainage tube was placed in the incision and the incision was closed.\u003c/p\u003e \u003cp\u003eAfter posterior cervical semi-laminectomy decompression fusion surgery, the target vertebra was first located under the C-arm X-ray machine, the median posterior cervical incision was made, the spinous process of the target segment and bilateral laminae were exposed, the needle insertion point and Angle were determined according to Magerl technique, lateral mass screws were placed on both sides of the segment scheduled for decompression, and the C-arm X-ray machine fluoroscopy confirmed the good position of the screws. Titanium rods of appropriate length were selected and precurved, and the precurved rods were inserted and fixed with nuts to restore the physiological lordosis of the cervical spine as much as possible. The laminae on the side of the hematomas pressing in the fixed segment were removed with a grinding drill and a bone rongeur. Black coagulated hematomas could be seen after the ligamenta flandum was removed. After repeated rinses with 0.9% sodium chloride saline were used to remove the hematomas, possible hemorrhagic points in the surrounding tissues and ruptured venous plexus were thoroughly examined (see Fig.\u0026nbsp;1), and the hemorrhagic points were coagulated with bipolar electrocoagulation. Bone fragments implanted in the contralateral laminae were polished by grinding and drilling, and bone fusion was performed. Place a drainage tube inside the incision and close the incision.\u003c/p\u003e \u003cp\u003eAll patients were immediately fixed with neck girth after surgery, drainage was removed after the drainage volume was less than 30ml for 24\u0026thinsp;~\u0026thinsp;48h, and rehabilitation activities were performed after 48h in bed with neck sitting around and/or getting up. Neck girth was fixed for 4 weeks after surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Follow-up\u003c/h2\u003e \u003cp\u003eThe position of cervical implant fixation and cervical curvature were evaluated by routine postoperative radiographs. All patients were followed up for 1, 3, 6, 12, and 18 months. Radiographs were used to determine the location of postoperative fixation and possible faults, CT scans were performed to understand the bony spinal canal, and MR Examinations were performed every 12 months to understand the spinal cord (see Fig.\u0026nbsp;3). Function was evaluated clinically by ASIA scale, JOA and VAS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Statistical method\u003c/h2\u003e \u003cp\u003eSPSS 18.0 (SPSS, USA) statistical software was used for analysis. Measurement data were expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s and one-way analysis of variance was used\u003c/p\u003e \u003cp\u003eDifferences at different time points were compared, or paired T-test was used to compare preoperative and postoperative indicators. Counting data were tested by chi-square test. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Statistical result\u003c/h2\u003e \u003cp\u003eAll patients in this group successfully completed the operation and were followed up for 12 to 36 months (mean 16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 months). All patients achieved grade ASIA remission within 1 week after surgery. Of the 23 patients with neurological impairment, 18 of them recovered to grade E in ASIA one month after surgery (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The VAS scores at 7 days and 3 months after surgery showed a decrease in compliance, with the average preoperative score (7.29\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35) and the average postoperative score at 3 months (2.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The average preoperative JOA score was (8.38\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22) and (12.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66) three months after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among them, the functional recovery of patients operated within 8 hours of the onset of surgery was similar to that of patients operated within 8\u0026ndash;24 hours of the onset of surgery, and there was no statistical significance in the functional evaluation of postoperative JOA and VAS scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The functional recovery of patients operated within 24 hours was better than that of patients operated after 24 hours. The functional evaluation of JOA and VAS scores after surgery had statistical significance (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNo postoperative infection or vascular injury occurred in all patients until the last follow-up. Postoperative pulmonary infection occurred in 2 cases, which recovered after treatment with nebulization and sensitive antibiotics. No rebleeding was found in all patients at the last follow-up, the spinal canal volume was good, bone grafting was completely healed, and no internal fixation loosening or cervical kyphosis occurred.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eASIA grades of the patients preoperatively and during the follow-ups after the operation (n\u0026thinsp;=\u0026thinsp;cases)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrade 7 Days After the Postoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe Last Follow-up\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD\u003c/p\u003e \u003cp\u003eE\u003c/p\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 0\u003c/p\u003e \u003cp\u003e0 0\u003c/p\u003e \u003cp\u003e2 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 7\u003c/p\u003e \u003cp\u003e0 0\u003c/p\u003e \u003cp\u003e18 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVAS scores for comparison (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVASScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber of Cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBefore the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 Week After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eThe Last Follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u0026lt;8h\u003c/p\u003e \u003cp\u003e8-24h\u003c/p\u003e \u003cp\u003e\u0026gt;24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e \u003cp\u003e7.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003cp\u003e6.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.47\u0026thinsp;\u0026plusmn;\u0026thinsp;2.46\u003c/p\u003e \u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003cp\u003e2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003cp\u003e1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003cp\u003e0.022\u003c/p\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNote: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 means that the difference is statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eJOA scores for comparison (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJOAScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 Week After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12 Months After the Operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThe Last Follow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;8h\u003c/p\u003e \u003cp\u003e8-24h\u003c/p\u003e \u003cp\u003e\u0026gt;8h\u003c/p\u003e \u003cp\u003ePValue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.21\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003cp\u003e8.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003cp\u003e8.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.27\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003cp\u003e10.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.87\u003c/p\u003e \u003cp\u003e9.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.47\u003c/p\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e \u003cp\u003e12.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e \u003cp\u003e11.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.34\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003cp\u003e13.03\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e \u003cp\u003e12.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.83\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e \u003cp\u003e13.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3412.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e \u003cp\u003e14.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e \u003cp\u003e12.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 means that the difference is statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Typical cases (Figs.\u0026nbsp;1, 2, 3)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3 Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Clinical characteristics\u003c/h2\u003e \u003cp\u003eAcute intraspinal epidural hematoma was first reported by Jackson R. Case of spinal apoplexy in the Lancet in 1869 [J]. Lancet, 1896, 94(2392): 5\u0026ndash;6. Alexiadou-Rudolf C et al. calculated that spontaneous cervical epidural hematoma accounted for 0.3% to 0.9% of epidural lesions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. 1. Alexiadou-Rudolf C, Ernestus RI, Nanassis K, et al. Acute nontraumatic spinal epidural hematoma. An important differential diagnosis in spinal emergencies[J]. Spine, 1998, 23(16):1810\u0026ndash;1813. Spontaneous hemorrhage in the spinal canal is more common in adults, but it can occur at any age. The age distribution in this group was 35\u0026ndash;68 years old, with an average age of 42.7 years. Similar to reports by Shin JJ et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Shin JJ, Kuh SU, Cho YE, et al. Surgical management of spontaneous spinal epidural hematoma [J]. Eur Spine,2006, 15(6):998\u0026ndash;1004. Clinical mainly acute onset, sudden onset, there are intracranial and thoracoabdominal pressure suddenly increased induction factors, such as labor, jumping, defecation, emotional excitement, laughter and sneezing. At the same time, acute pain in the neck and its innervation area corresponding to the involvement of the hematoma may occur in a short time, sensory and motor dysfunction below the injury plane, and even complete paralysis (delayed paralysis with reduced reflexes is more common). The main symptoms of the patients were bilateral nerve function deficit in the diseased segment. For patients who experience sudden neck pain and nerve root pain symptoms, acute cervical spinal epidural hematoma should be regarded as a possible differential diagnosis case[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003e3.2 Pathological feature\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eHentschel et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] believed that rupture of epidural venous plexus, rupture of malformed blood vessels and rupture of epidural artery were the main causes of hematoma. Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases[J]. Spine, 2001, 26(22): E525-E527. Meanwhile, most of the patients in this group have a history of hypertension for many years, and its mechanism may be similar to that of hypertension causing strok[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. At the same time, we found that most patients also had type 2 diabetes. We believe that long-term hypertension and diabetes may lead to vascular lesions in the spinal canal, increased brittleness, and easy to rupture during acute pressure changes. On imaging, hematoma is usually located on the dorsal side of the spinal cord, which is closely connected with the ventral venous plexus of the spinal cord and the posterior longitudinal ligament, and the lacuna is small and dense. The dorsal epidural of the spinal canal is mostly composed of adipoid tissue with sparse structure and rich venous plexus. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Groen RJ. Non -operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases [J]. Acta Neurochir (Wien), 2004,146(2): 103\u0026ndash;110. However, hematoma occurred in the ventral side of the spinal cord in two patients in this group, and it cannot be ruled out that these two patients were caused by arterial malformation rupture.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Imaging performance\u003c/h2\u003e \u003cp\u003eMRI plain scan plus enhanced examination is an important method for definitive diagnosis, and it is also the gold standard for clinical diagnosis. All patients reviewed in our hospital showed signs of epidural hematoma on MRI. The signal changes of MRI were mainly related to the bleeding time, especially the characteristic changes of T2WI: hyperacute stage (\u0026lt;\u0026thinsp;24h) : T1WI signal level, T2WI high signal; Acute phase (1\u0026thinsp;~\u0026thinsp;3d) : T1WI signal, T2WI low signal; Early subacute stage (3\u0026thinsp;~\u0026thinsp;7 days) : T1WI high signal, T2WI low signal; In the late subacute stage (7\u0026ndash;14 days), both T1WI and T2WI showed high signal. Chronic phase (\u0026gt;\u0026thinsp;14 days) : High signal on T1WI and T2WI. In chronic phase, enhanced MRI scan can show banding enhancement around hematoma. MRI is also an important test to distinguish acute epidural hematoma from other epidural lesions such as epidural abscess, epidural angiolipoma, cavernous hemangioma, metastasis, lymphoma, etc. In other tests, if the cause of bleeding is a cavernous hemangioma, DSA often shows no positive findings, or only an uncharacterized lack of vascular lesions. MRI showed local myelocele with mixed signals in the tumor. From the clinical standpoint, it is paramount that suspected SSEH patients undergo the proper screening in a timely fashion. MRI showing T2 hyperintensity within the spinal cord within 24 h is a poor prognostic indicator[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In a study involving 20 patients with SEH, Chang et al[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported that most of the hematomas examined within 36 hours after the onset of symptoms showed uniform and equal signals on T1-weighted images compared to the spinal cord, and uniform high signals on T2-weighted images. However, in magnetic resonance imaging conducted more than 36 hours after the onset of symptoms, it was found that some hematomas showed uneven equal signals or high signals on T1-weighted images, and mixed high and low signal changes on T2-weighted images. For the assessment of the severity of neurological function in acute SSEH, traditionally, the ASIA classification was relied upon. However, the value of imaging indicators has gradually gained attention. Honda et al. conducted a multicenter study that filled this gap - by analyzing the T2-weighted MRI images of 57 patients, they first clearly identified that the low-signal layer around the hematoma (pathologically confirmed as the collagen capsule), the uneven signal within the hematoma (indicating continuous bleeding), and the spinal canal occupancy rate (COR)\u0026thinsp;\u0026gt;\u0026thinsp;40% were independent imaging markers for predicting severe paralysis. This provided a quantitative basis for clinicians to quickly determine the severity of the condition through MRI[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Treatment\u003c/h2\u003e \u003cp\u003eAs the treatment of the disease, the literature content is varied, generally divided into two ways: 1. Conservative treatment, 2 surgical treatment.\u003c/p\u003e \u003cp\u003eSince Priest first reported on conservative treatment of SSEH in 1935, some scholars have reported cases of conservative treatment of SSEH, some of which have achieved satisfactory result[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. 3. Groen RJ. Non -operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases [J]. Acta Neurochir (Wien), 2004,146(2): 103\u0026ndash;110.\u003c/p\u003e \u003cp\u003e4. Duffill J, Sparrow OC, Millar J, et al. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases[J]. J Neurol Neurosurg Psychiatry, 2000,\u003c/p\u003e \u003cp\u003e69(6): 816\u0026ndash;819.\u003c/p\u003e \u003cp\u003eThey considered that conservative treatment should be attempted in the following cases: (1) patients with mild neurological impairment with an AISA or Frankel grade of E; (2) Patients with an AISA or Frankel grade of C/D, but with gradual recovery of neurological function; (3) Early recovery of neurological function after onset, and progressive improvement; (4) Patients with obvious surgical contraindications. After the onset of SSEH, neurological function improvement and hematoma absorption can be seen in some patients at an early stage, and the possible mechanisms are \"hematoma diffusion\" and \"hematoma leakage\";(5) Cases of spontaneous epidural hematoma with mild symptoms or those showing improvement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. 5. Hentschel SJ, Woolfenden AR, Fairholm DJ. Resolution of spontaneous spinal epidural hematoma without surgery: reportof two cases[J]. Spine, 2001, 26(22): E525-E527. The former means that the hematoma spreads along the epidural space and thus \"decompresses itself,\" while the latter means that the hematoma can partially leak out of the foramina, thereby reducing intravertebral pressure and reducing spinal cord and nerve compression. Conservative treatment is subject to many limitations, such as the judgment of neurological function, the progression of the patient's symptoms, and the judgment of blood volume, etc., such as the judgment error will delay the treatment time of the patient. At the same time, many conservatively treated patients have a legacy of chronic pain in the dominant area of the responsible segment, and loss of motor and sensory function. During conservative treatment, the interruption of anticoagulant therapy is not always necessary,especially when the clinical symptoms improve on their ow[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Conservative management has proven effective, although feasible only if spontaneous recovery is manifested[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Conservative treatment could not prevent occurrence of multiple episodes or rebleeding in patients. Microsurgery should be recommended as the preferred treatment strategy for SSEH[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, most scholars advocate early decompression of spinal canal and removal of hematoma in order to recover nerve function as soon as possible. Based on our reported cases and literature review, we believe that stage I surgical decompression has the highest benefit rate for patients. Hussenbocus SM, Wilby MJ, Cain C, et al. Spontaneous spinal epidural hematoma: a case report and literature review[J]. Emerg Med, 2012, 42(2): e31-34. Liao CC, Hsieh PC, Lin TK, et al. Surgical treatment of spontaneous spinal epidural hematoma: a 5-year experience[J]. Neurosurg Spine, 2009, 11(4): 480\u0026ndash;486. (in Chinese) Although some patients have a certain effect of conservative treatment, the long cycle of conservative treatment and the prolonged bed rest of patients increase the incidence of complications, the length of hospital stay and the hospitalization cost of the whole treatment cycle.\u003c/p\u003e \u003cp\u003eLaminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce\u003c/p\u003e \u003cp\u003eclinical benefits[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Neurosurgical intervention for SSEH yields positive outcomes and benefits patients. Patients with higher preoperative ASIA, MRC grade, and those presenting with preserved saddle sensation may experience further improved clinical outcomes after intervention[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Prompt surgical evacuation of the hematoma leadsto afavorable neurological outcome, whereas delay in treatment can bedisastrou[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSignificant neurological recovery after surgical decompression of SSEHs can be achieved, despite[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Even in cases where CT scan is negative, the working diagnosis should be hemorrhage with cord compression, and spine MRI should be urgently performed. Once a diagnosis is achieved, we recommend urgent surgical decompression of the spinal cord[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Prompt surgical decompression is valuable, irrespective of the time interval between symptom onset and operation in infant[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ethe significant preoperative neurological deficits, spinal cord changes on MRI, and delayed timing of intervention.\u003c/p\u003e \u003cp\u003eAt the same time, the absorption rate of hematoma is slow, and the patient's spinal cord will be compressed for a long time, which will lead to the limited recovery of nerve function, and eventually lose the recovery opportunity. Even if some patients do not have further neurological function, some neurological function loss remains.\u003c/p\u003e \u003cp\u003eIn the cases we reviewed, Stage I surgical decompression was shown, and all patients achieved good neurological function improvement at 7 days after surgery. The two groups of patients who underwent decompression within 24 hours after the onset of the disease had similar neurological function benefits. The main reason was that this type of epidural hematoma was mostly caused by venous rupture and bleeding. The low venous pressure limited the amount of blood loss within the relatively limited space of the spinal canal, and the amount of blood loss decreased with the increase of the pressure in the spinal canal, and the process of pressure induction was slow, limiting the further loss of nerve function. This is the opposite mechanism of acute traumatic spinal cord injury. However, when the bleeding time is prolonged and the hematoma reaches the maximum value, the spinal cord function is correspondingly damaged to the greatest extent. Even though the hematoma may have a small volume of self-absorption, the damage is irreparable.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Conclusions","content":"\u003cp\u003eAlthough some cases have been reported in which patients recovered after conservative treatment, our study shows that surgical intervention is clearly relevant in this population of patients with acute intramural hemorrhage, regardless of neurological impairment. The review showed that decompression surgery was completed within 24 hours of the onset of the disease, the prognosis of the patients was significantly improved, and the patients who had more than 24 hours had to undergo decompression surgery, although the recovery of neurological function may be limited, but the further deterioration of neurological function was prevented.\u003c/p\u003e"},{"header":"5 Restrict","content":"\u003cp\u003eThe study has several limitations, most notably its retrospective nature. The lack of direct case controls, particularly those related to clinical outcomes in non-surgical patients, makes it impossible to directly compare the efficacy of surgical versus non-surgical interventions in patients with acute intraspinal hemorrhage. Limitations also include the small sample size of patients included in our study, which was insufficient for statistical analysis of univariate and multivariate variables and the estimation of the corresponding influence size, and limited the statistical ability to analyze the risk factors of preoperative and postoperative complications.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study involving human participants and human data was conducted in full compliance with the ethical principles outlined in the World Medical Association (WMA) Declaration of Helsinki The protocol was reviewed and approved by the Ethics Committee of the People's Hospital of Guangxi Zhuang Autonomous Region (KY-IIT-2020-02). All procedures were performed in accordance with local legislation, institutional requirements, and the core tenets of the Declaration of Helsinki, including principles related to the protection of participants\u0026rsquo; health, dignity, autonomy, privacy, and confidentiality of personal information.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIn accordance with national legislation and institutional requirements for retrospective studies of this nature, written informed consent from participants or their legal guardians/next of kin was not required, as the research involved the anonymized review of existing medical records and imaging data without direct interaction with participants. This exemption was approved by the aforementioned Ethics Committee and is consistent with the Declaration of Helsinki\u0026rsquo;s provisions for minimizing unnecessary burdens on participants when research poses minimal risk and cannot be feasibly conducted otherwise.\u003c/p\u003e \u003cp\u003eAll efforts were made to ensure that the rights and welfare of participants were safeguarded throughout the study, and the potential benefits of the research (advancing understanding of optimal surgical timing for SCSEH) outweighed any minimal risks associated with retrospective data analysis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was supported by the Guangxi Natural Science Foundation (Project Number: 2023GXNSFAA02628523) and was awarded to Dr. Haoxi Li.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003ePlease use initials to refer to each author's contribution in this section, for example: \"FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.\"\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003cp\u003eClinical Trial Number\u003c/p\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003cp\u003e Consent for Publication\u003c/p\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe raw data supporting the findings of this study are not publicly available. This restriction is primarily due to the fact that the data contain sensitive personal health information (PHI) of participants, including detailed medical records, imaging data, and clinical assessment results. Disclosure of such information could compromise the privacy and confidentiality of individual participants, which is strictly protected in accordance with national data protection regulations, institutional ethical guidelines, and the principles of the Declaration of Helsinki.Additionally, the data are part of the institutional medical record system, and access is restricted to authorized personnel for clinical and research purposes only. While we recognize the value of data sharing for scientific advancement, we prioritize the protection of participants\u0026rsquo; rights and welfare. Aggregated and de-identified data used to generate the key results presented in this manuscript are available from the corresponding author upon reasonable request, subject to review and approval by the Ethics Committee of the People's Hospital of Guangxi Zhuang Autonomous Region to ensure compliance with ethical and legal requirements.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJackson R, CASE OF SPINAL. APOPLEXY Lancet, 1869. 94(2392): pp. 5\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarik SI, Raichle ME, Reis DJ. Spontaneously remitting spinal epidural hematoma in a patient on anticoagulants. N Engl J Med. 1971;284(24):1355\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsumura A, et al. Clinical management for spontaneous spinal epidural hematoma: diagnosis and treatment. Spine J. 2008;8(3):534\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoltas S, Heiling M, Lonntoft M. Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology. 1996;199(2):409\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLonjon MM et al. Nontraumatic spinal epidural hematoma: report of four cases and review of the literature. Neurosurgery, 1997. 41(2): pp. 483-6; discussion 486-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh C, et al. Spontaneous spinal epidural hematomas of cervical spine: report of 4 cases and literature review. Am J Emerg Med. 2006;24(6):736\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndour H, et al. Pain in the back after a brain trauma\u0026mdash;The revelation of a spinal subdural hematoma: A case report with a literature review. SAGE Open Med Case Rep. 2023;11:2050313X231204771.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim T, et al. Clinical Outcomes of Spontaneous Spinal Epidural Hematoma: A Comparative Study between Conservative and Surgical Treatment. J Korean Neurosurg Soc. 2012;52(6):523.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang S, et al. Spontaneous cervical epidural hematomas in mild cervical spondylotic myelopathy patients: An analysis of 8 cases. J Huazhong Univ Sci Technol [Medical Sciences]. 2017;37(2):248\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo M, He M, Wu C. Prognosis and outcome of chronic pain after spontaneous spinal epidural hematoma. Acta Neurol Belgica. 2023;123(5):1849\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakanishi K, et al. Hemiparesis caused by cervical spontaneous spinal epidural hematoma: a report of 3 cases. Adv Orthop. 2011;2011:516382.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWajngarten M, Silva GS. Hypertension and Stroke: Update on Treatment. Eur Cardiol. 2019;14(2):111\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiani B, et al. Spontaneous cervical epidural hematoma: Insight into this occurrence with case examples. Surg Neurol Int. 2021;12:79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang FC, et al. Evaluation of clinical and MR findings for the prognosis of spinal epidural haematomas. Clin Radiol. 2005;60(7):762\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHonda S, et al. Neurological severity evaluation using magnetic resonance imaging in acute spontaneous spinal epidural haematomas. Int Orthop. 2022;46(10):2347\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuyukkaya R, et al. Rapid spontaneous recovery after development of a spinal epidural hematoma: a case report. Am J Emerg Med. 2014;32(3):e2911\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUchiyama T, Gomi A, Kawai K. Recurrent cervicothoracic spontaneous epidural hematoma in a toddler. Child's Nerv Syst. 2025;41(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpontaneous Cervical Epidural Hematoma. A Case Report.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillas C, Silva A, Alfonso M. Pure cervical radiculopathy due to spontaneous spinal epidural haematoma (SSEH): report of a case solved conservatively. Eur Spine J. 2006;15(S5):569\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu J, et al. Spontaneous Spinal Epidural Hematoma: A Study of 55 Cases Focused on the Etiology and Treatment Strategy. World Neurosurg. 2017;98:546\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenga P, et al. Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications. Acta Neurochir. 2023;165(4):905\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan DTM, et al. Spinal shock in spontaneous cervical spinal epidural haematoma. Acta Neurochir. 2004;146(10):1161\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGopalkrishnan CV, Dhakoji A, Nair S. Spontaneous cervical epidural hematoma of idiopathic etiology: Case report and review of literature. J Spinal Cord Med. 2013;35(2):113\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaeesa S, et al. Spontaneous Spinal Epidural Hematoma: Correlation of Timing of Surgical Decompression and MRI Findings with Functional Neurological Outcome. World Neurosurg. 2019;122:e241\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajz G, et al. Spontaneous spinal epidural hematoma: The importance of preoperative neurological status and rapid intervention. J Clin Neurosci. 2015;22(1):123\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee J, et al. Spontaneous spinal epidural hematoma in a 4-month-old infant. Spinal Cord. 2007;45(8):586\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cervical spine, spinal epidural hematoma, surgery timing, MRI","lastPublishedDoi":"10.21203/rs.3.rs-8262636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8262636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSCSEH ( Spontaneous cervical spinal epidural hematoma) is a rare yet serious clinical entity characterized by idiopathic, non-traumatic, and non-iatrogenic accumulation of blood in the cervical epidural space. For patients who experience sudden neck pain and nerve root pain symptoms, acute cervical spinal epidural hematoma should be regarded as a possible differential diagnosis cas.In recent years, such cases have been reported globally, yet treatment strategies remain heterogeneous with inconclusive efficacy evidence. While surgical decompression is widely advocated for optimal neurological recovery, conventional protocols lack specificity regarding optimal intervention timing.Over a 13-year period, we surgically managed 36 SCSEH cases. This study analyzes the intervals from symptom onset to hospital admission and admission to surgical intervention, with comparative assessment of postoperative neurological outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted on 36 patients (23 males and 13 females; mean age 48.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 years) diagnosed with SSCEH between January 2006 and January 2019. All patients presented with varying degrees of neurological deficits upon admission and underwent single-stage surgical intervention comprising cervical spinal canal decompression, epidural hematoma evacuation, and internal fixation. Patients were categorized based on the time interval from symptom onset to surgery.Clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) score, Visual Analog Scale (VAS), and American Spinal Injury Association (ASIA) Impairment Scale. All patients achieved a minimum follow-up of 12 months (mean 16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 months). Radiographs, CT(computed tomography ), and MRI(magnetic resonance imaging ) were utilized to evaluate fusion status and spinal stability.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll 36 patients exhibited statistically significant improvements (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in ASIA grade, VAS score, and JOA score at the final follow-up compared to preoperative assessments. Functional recovery was comparable between patients undergoing surgery within 8 hours of symptom onset and those operated between 8 and 24 hours post-onset, with no statistically significant difference in postoperative functional outcomes (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, patients receiving surgical intervention within 24 hours demonstrated significantly superior functional recovery compared to those operated beyond 24 hours (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The postoperative follow-up imaging results indicated no rebleeding, no significant loss of cervical curvature, no collapse of the bone graft or no displacement of the implant, and good spinal canal volume.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePatients with SCSEH undergoing surgery within 8 hours of symptom onset demonstrated comparable postoperative functional recovery to those operated between 8\u0026ndash;24 hours. However, subjects receiving intervention within 24 hours collectively showed superior functional outcomes compared to those undergoing surgery beyond 24 hours\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003e The studies involving humans were approved by the Ethics Committee of People's Hospital of Guangxi Zhuang Autonomous Regionl. The studies were conducted in accordance with the local legislation and institutional require ments. Written informed consent for participation was not required from the participants or the participants\u0026rsquo; legal guardians/next of kin in accordance with the national legislation and institutional requirements.\u003c/p\u003e","manuscriptTitle":"Does different operation timing for spontaneous cervical spinal epidural hematoma lead to different prognosis? 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