Acute spontaneous spinal subdural hematoma in a patient with bilateral incarcerated inguinal hernia

Objective: Acute spinal subdural hematoma is an infrequent and devastating condition that occurs mostly in patients with coagulopathy or receiving anticoagulants. It may also develop after trauma, spinal surgery or iatrogenically (lumbar puncture and/or spinal anaesthesia). Spinal vascular malformations or spinal tumours can also be the origins of subdural hematomas. However, acute spinal subdural hematomas, which are not associated with these risk factors, are seen even more infrequently. In this report, we have described a case of spontaneous acute spinal subdural hematoma that occurred in a patient with bilateral incarcerated inguinal hernia and discussed the possible pathomechanisms. Methods: A 50-year-old male was admitted to the emergency department for the acute onset of interscapular pain, slight weakness in both legs and urinary retention. Neurological examination revealed paraparesis (3/5 in left, 4/5 in right) and hypoesthesia below T5 dermatome. He had long-standing bilateral inguinal hernia and constipation for the last 5 days. Magnetic resonance imaging of the spine displayed an extramedullary acute hematoma at the T4-8 levels but it was impossible to identify whether the hematoma was extradural or intradural exactly. The patient underwent an urgent operation via T4-6 laminectomy. After opening the dura, an extensive, partially organized hematoma was completely removed by aspiration. Muscle strength was improved immediately; urinary retension was recovered on postoperative day 7. Constipation was relieved on postoperative day 4. Conclusion: Acute spinal subdural hematoma is an emergency condition in case of neurological compromise. Urgent surgical evacuation of hematoma results in good outcome. In the case of unidentified etiologies, the conditions that could play a role in increased intraabdominal and/or intrathoracic pressure should be considered always. (C) 2008 Elsevier Masson SAS. All rights reserved.