J Korean Med Sci 2005; 20: 331-4 ISSN 1011-8934 Copyright The Korean Academy of Medical Sciences The Poor Outcome of the Delayed Diagnosis of Acute Spontaneous Spinal Epidural Hematoma : Two Cases Report We present two patients who had acute paraplegia with sensory loss due to spon- taneous spinal epidural hematoma (SSEH). One had myocardial infraction and the other had deep vein thrombosis, and the former was treated with anticoagulants and the latter was treated with thrombolytic agent. We analyzed the neurological status of our two cases each between its preoperative and postoperative state. Postopera- tively both showed no improvement of neurologic symptom, and on follow-up of 12 months, one showed no neurologic improvement and the other showed a insignifi- cant improvement of lower extremity muscle power (trace knee extensor/ankle dorsi- flexor). We thought that this poor outcome was due to delayed operation, which was done more than 24 hr after the symptom onset. The outcome in SSEH is essentially determined by the time taken from symptom onset to operation. Therefore, early and precise diagnosis such as careful history taking and MRI evaluation is necessary. Key Words : Diagnosis; Hematoma, Epidural, Spinal; Surgical Procedures, Operative Kyung-Jin Song, Kwang-Bok Lee Department of Orthopaedic Surgery, College of Medicine, Institute for Medical Science, Chonbuk National University Medical School, Chonju, Korea Received : 17 February 2004 Accepted : 3 May 2004 Address for correspondence Kwang-Bok Lee, M.D. Department of Orthopedic Surgery, Cheju National University Medical School, 154 Samdo2-dong, Jeju 690-716, Korea Tel : +82.64-750-1265, Fax : +82.64-726-0173 E-mail : osdr2815@chol.com INTRODUCTION Spontaneous spinal epidural hematoma (SSEH) represents 0.3-0.9% of spinal epidural space-occupying lesions. The clin- ical course has characteristics: without preceding trauma, patients experience an acute onset of local discomfort or pain, sometimes with radicular paresthesia. Within hours, signs of spinal cord compression appear, presenting as progressive paraplegia and loss of sensory function. Despite the clinical syndrome of SSEH is relatively characterized, its exact diag- nosis may be difficult. It is important to recognize these signs since early diagnosis and prompt surgical evacuation provide the maximum chance of functional recovery. CASE REPORT Case 1 A 51-yr-old man with a history of myocardial infarction was treated with percutaneous transluminal coronary angio- plasty. After being discharged, he visited the department of internal medicine for three months and was taking 200 mg/ day of Aspirin. The patient felt the discomfort of midback area and mild lower extremity weakness 11 days before admit- ted to emergency room (ER). He ignored these discomforts which was not a great deal in his daily activity and on the 331 11th day from the onset of symptoms, he swam as usual in a pool for about 1 hr. After swimming, he felt worsening back pain and aggravated lower extremity weakness and so he visited ER and was examined by a physician in ER. His physician noticed the rapidly progressive paraplegia and a loss of leg sensory function, and consulted the department of neurology. Neurologic physician who suspected the acute spinal cord disorder, ordered high dose steroid injection and serial neurologic examination. The neurologist thought this patient’s symptom was not a surgical condition but a medical condition. The following day neurologist reexamined the neu- rologic status. The patient’s neurologic status showed com- plete paraplegia in the lower extremity, T10-T12 dermatome hypesthesia, L1 below dematome anesthesia, no bladder func- tion, patella tendon reflex (-/-), and ankle jerk (-/-). His coag- ulation profile showed PT: 0.85 (0.9-1.10 INR), aPTT: 40.2 (29.8-41.8 sec). The neurologist ordered MRI. MRI scan showed an epidural hematoma with spinal cord compression from T8 to L2 (Fig. 1, 2). Then the neurologist consulted depart- ment of orthopedic surgery. It was 28 hr after symptom onset, we performed the bilateral decompressive laminectomy from T 8 to L2 immediately. A large posterolateral hematoma and old blood clot was found within the epidural space (Fig. 3). No neurologic improvement was noted after surgery. On fol- low-up 21 months, his neurologic status showed a complete paraplegia, L1 below anesthesia, no bladder function and no deep tendon reflex.