Discussion:
Possible causes of spontaneous SSDH are minor or major spine trauma and
non-traumatic causes including anticoagulant therapy, coagulopathy and
vascular anomalies (aneurysm, dural arteriovenous fistula (AVF), toxemia
of pregnancy, and idiopathic SSDH (4, 5). Pathophysiology of spontaneous
SSDH can be the rupture of the radiculomedullary veins in the
subarachnoid space following the trauma or increased intra-abdominal or
intra-thoracic pressure (15). The lesion often develops on the thoracic
and lumbar spinal and rarely in the cervical area (3). Our patient
presented with severe sudden onset cervical pain, left side weakness and
Brown Squared symptoms for two days before admission. For diagnosis of
spontaneous SDH, MRI is considered the gold standard in evaluation and
monitoring of spinal hematomas. Based on post-hemorrhage period,MRI finding will be changed. Within the first few hours, the clot shows
iso-intensity in T1WI and hyper-intensity in T2WI. In the first 48
hours, hematoma shows hypo-intensity on T1W1 and hypo-intensity on T2W1.
After 2 days till 1 week, hyper-intensity and hypo-intensity in T1WI and
T2WI were seen, respectively (1, 21). In our evaluation, hyper-intensity
on T1-weighted and hypo-intensity on T2- weighted appeared. Based on
physical examination and MRI findings, spontaneous SSDH was diagnosed in
early sub-acute stage. Treatment management in previous studies was
based on the severity of neurological deficits. Non-operative treatment
may be chosen in patients with minimal neurological deficits, but in
those with major deficits, rapid deterioration of clinical and
radiological signs and symptoms drainage or surgery should be performed,
as we did in our case. Early surgery and aggressive approach is a viable
option even in long-lasting spinal cord compression. It is evident that
the outcome mainly varies on the basis of clinical conditions and lesion
levels (1). In the present study, our patient showed severe neurological
deficits and underwent C3-C7 levels laminectomy; he showed, however, a
satisfactory late follow up, indicating the short period of time between
the onset of the symptoms and the surgical treatment (at most 24 h). It
is worth mentioning that those with paraplegia and bladder and bowel
dysfunction show lower prognosis, irrespective of conservative or
surgical decompression. In adult patients, conservative laminectomy at
the cervical surface does not necessarily affect the spinal stability.
Based on the authors’ knowledge and literature review, our patient was
the first C3-C7 SSDH report treated with C3-C7 laminectomy. As a result,
in such cases, posterior fixation is not performed.