Working Diagnosis:
Lumbar epidural mass

Treatment:
Due to the acute neurological change coupled with the severity of spinal canal stenosis on MRI, the patient was taken to the operating room for an urgent lumbar decompression and L3-L4 laminectomy. During the surgery, a bilateral pars defect was identified at the level of L4 and upon opening the ligamentum, an epidural hematoma was identified. The neurosurgeon was able to evacuate the hematoma.

Outcome:
The patient tolerated the procedure well and was admitted to the pediatric intensive care unit in stable condition for postoperative recovery. Repeat MRI of the lumbar spine showed resolution of the spinal canal stenosis and no evidence of a spinal mass. The patient was discharged on postoperative day 4. Five months after surgery, the patient had complete resolution of all neurological deficits and was cleared to lift up to 150 lbs. He was not yet cleared to return to contact sports.

Author's Comments:
Spinal epidural hematomas are incredibly rare, affecting approximately 1 in 1,000,000 people per year. Spinal epidural hematomas can be secondary to trauma, iatrogenic, or spontaneous. Spontaneous spinal epidural hematomas can occur whenever there is an increase in intraspinal pressure due to a straining activity such as weight lifting, leading to rupture of the postero-internal vertebral venous plexus. They can also occur in the setting of spondylolysis. The leading hypothesis for this patient is that chronic stress in the lumbar spine accumulated over time due to the patient's high activity level and weight lifting regimen, which lead to the development of a spontaneous spinal epidural hematoma. Spinal epidural hematomas can lead to rapid and permanent neurological deficits, and therefore, prompt recognition and neurosurgical consultation is essential to optimize care.

Editor's Comments:
Although rare, the most common cause of spontaneous spinal epidural hematoma is trauma or sport-related injury. Activities resulting in spinal epidural hematomas may vary drastically in intensity from stretching exercises to weightlifting. While trauma and surgery are known risk factors for developing a spinal epidural hematoma, risk factors for spontaneous spinal epidural hematomas are less well-defined. Some authors suggest an association with coagulopathies, platelets dysfunctions, arteriovenous malformations, pregnancy, and uncontrolled hypertension. The imaging modality of choice is an MRI. Spinal epidural hematomas appear hyperintense on T2-weighted images but change from isointense to hyperintense on T1-weight images approximately 24 hours after symptom onset. Poor prognostic indicators include poor neurologic status prior to intervention, presence of sensory symptoms, thoracic spine involvement, and more severe symptoms within a shorter time frame.

References:
Figueroa, J., DeVine, J. (2017). Spontaneous spinal epidural hematoma: literature review. Journal of Spine Surgery, 3(1), 58-63. doi: 10.21037/jss.2017.02.04.

Nagata, K., Ariyoshi, M., Ishibashi, K., Hashimoto, S., Inoue, A. (1998). Chronic lumbar epidural hematoma in a patient who had spondylolysis at the third lumbar vertebra. Report of a rare case involving a seventeen-year-old adolescent. J Bone Joint Surg Am, 80(10), 1515-20. doi: 10.2106/00004623-199810000-00013. PMID: 9801220

Ohaegbulam, C.O., Dunn, I.F., d'Hemecourt, P., Proctor, M.R. (2008). Lumbar epidural hematoma associated with spondylolyses. J Neurosurg Spine, 8(2):174-80. doi: 10.3171/SPI/2008/8/2/174. PMID: 18248290.

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