Spinal sub-dural hemorrhage is known to be a very rare entity. Only 93 cases of acute and sub-acute spinal sub-dural hemorrhage and around 30 cases of chronic spinal sub-dural hemorrhage of varying etiology have been described in literature 1. A multitude of etiologies have been associated with spinal subdural hemorrhage including bleeding diatheses, pharmacological anticoagulation, vascular malformations, lumbar puncture, epidural anesthesia and spinal surgery 1,2. Of particular interest, traumatic sub-dural hemorrhage and not associated with head injury (intra-cranial bleed) is extremely rare 1,2. Till June 2016, only 14 cases have been reported in literature of traumatic spinal sub-dural hemorrhage (TSSDH) 2. Despite extensive literature search on the subject of TSSDH, no reference could be found after June 2016 up to the time of writing this article. Hence, we are convinced to report the 15th overall case of traumatic spinal subdural hemorrhage (TSSDH).  Of the 14 reported cases of TSSDH, only one case is described with extensive involvement from dorsal to sacral spine 1. Definitive pathophysiological mechanism remains unclear although theoretical explanations have been proposed2. Due to unclear pathophysiology and rare incidence, universally accepted management guidelines are not available 1,2. We report an interesting 15th overall case of TSSDH (not associated with head injury)and only the second case of extensive traumatic sub-dural hemorrhage extending from dorsal to sacral spine and first case of extensive TSSDH that has been managed with expansive laminoplasty with durotomy for neural decompression and hematoma evacuation.  

68 year old male with no known previous co-morbidity presented with history accidental fall in a ditch over back during farm work. Following this, there was sudden onset mid and lower backache along with inability to move his both lower limbs along with tingling and numbness in abdomen and both lower limbs. There was no history of radiating pain or sphincter disturbance. He presented to our center after 5 days of trauma. On examination, he had increased tone in lower limbs (modified Ashworth scale grade 2 in right lower limb and grade 3 in left lower limb); power was MRC grade 4/5 in right lower limb at all joints; MRC grade 4-/5 in left hip joint, 4-/5 in left knee joint, 0/5 in left ankle and left EHL; bilateral knee and ankle jerks were exaggerated and plantars were bilateral extensor.    All modalities of sensations were decreased by 30% below D9 segmental level. X ray of the dorsolumbar spine (Fig 1) showed old fracture of Dv12 along with focal kyphotic deformity (Cobb’s angle 29 degree).

MRI of the dorso-lumbo-scaral region (Fig 2a,bc,d) showed collection in the spinal canal extending from the Dv7-Sv2 level besides old fracture of Dv12. The collection was intra-dural extramedullary in location and slightly hyperintense on both T1 and T2 images. This collection was seen all around the cord and cauda equine roots causing severe compression of these neural structures. These features were suggestive of spinal sub-dural hematoma.

In view of traumatic extensive spinal sub-dural hemorrhage associated with neurological deficit, he was taken up for surgery. Expansive Laminoplasty from Dv7-Lv2 level along with durotomy and evacuation of sub-dural hematoma was done. Intra-op features suggested bluish discoloration of the duramater, altered colored blood collection in the sub-dural space under pressure with severe compression of spinal cord and cauda equina roots. There was no active bleed, tumor or AVM. Thorough saline irrigation was done to ensure complete hematoma evacuation and neural decompression. The laminoplasty segment was reposited and secured with titanium miniplates. Post-op recovery was uneventful. Patient showed significant improvement in power of lower limbs. Post-op NCCT (Fig 4a,b) and post-op MRI (Fig 5a,b) showed complete evacuation of the sub-dural collection without any compromise of the bony spinal canal.

Non-traumatic spinal sub dural hemorrhage is known to be associated with multitude of etiologies including lumbar puncture, epidural analgesia, bleeding disorders, therapeutic anticoagulation, spinal surgery, vascular malformations and tumors 1-7. Traumatic spinal sub-dural hemorrhage is extremely rare and only 14 cases have been reported in literature since Rader’s first case report in 1955 1-3. In 5 of 14 cases of TSSDH described, there was simultaneous intra-cranial bleed in the form of intra-ventricular hemorrhage, sub-dural hemorrhage, sub-arachnoid hemorrhage or intra-cerebral hemorrhage 1,3. Clinical manifestations depend on the location and degree of neural compression and includes paresis, monoplegia, paraplegia, quadriplegia, cauda equina syndrome and various sensory phenomena 1,8,9. The precise pathophysiological mechanisms of TSSDH are still poorly understood 1,3. It is hypothesized that indirect force on the intra-spinal vessels lead to transient intravascular-extravascular pressure differential which causes rupture and spinal SDH 1 . Whereas in cases of concomitant cranial and spinal bleed, the pressure from cranial space causes increase in the shearing forces between sub-dural and sub-arachnoid vessels which leads to tear in the inner dura and consequent spinal SDH 1. Our patient however did not have any concomitant head injury or cranial bleed. Early diagnosis of spinal SDH is of pivotal importance because prompt treatment is associated with better prognosis1,8,9,10. MRI has proven to be superior than CT in the management of spinal SDH 11,12. The most important factor to distinguish between SDH from other spinal lesions is identification of blood products, which are in various stages of degradation, in the sub-dural space. This helps in estimating duration of bleed especially in cases of spontaneous SSDH 12. MRI also provides better information regarding neural tissue compression 12. It is estimated that TSSDH was under reported in the pre-CT/MRI era 11,12. The degree of neural compression is maximum and therefore prognosis worst in thoracic lesions whereas in lumbar spine location the degree of neural compression is least and have better prognosis 1,2,8 . Prognosis of TSSDH is worse than non-traumatic spinal SDH and post-operative neurological deficit corroborates with pre-operative neurological deficits 1,8,9. There is increasing consensus that when neurological deficit is present, prompt surgical decompression should be attempted before irreversible damage takes place 1,2. Prognosis of TSSDH after SDH drainage beyond 3 months of trauma has poor prognosis 1. Also prognosis is worse in cases where neural compression is present at more than 3 levels 1. Six cases of TSSDH have been reported when patients were treated conservatively with steroids and repeated lumbar punctures 2,3. It is however noteworthy that all these patients had minimal or no neurological deficits. Moreover, it is uncertain whether steroids and repeated lumbar drainage leads to resolution of spinal SDH in conservatively managed patients or resolution is due to natural course of blood product resorption from sub-dural spaces 1,3.  According to analysis of clinical presentation and management of reported cases TSSDH by William, six patients were treated by Laminectomy for surgical evacuation 1. Also, Cooper treated his patient by laminectomy 2. Expansive Laminoplasty offers advantages in terms of maintaining spinal structural stability and achieving satisfactory neural decompression.

Our patient is only the 15th overall case of traumatic spinal sub-dural hemorrhage, only the second case of extensive traumatic sub-dural hemorrhage extending from dorsal to sacral spine and first case that has been managed with expansive laminoplasty with durotomy for cord decompression and hematoma evacuation.  

Traumatic spinal SDH is extremely rare entity. Definitive mechanisms are still poorly understood. Management guidelines for TSSDH are lacking. Prognosis is better in isolated lumbar spine location. When neurological deficit is present, prompt surgical evacuation is considered as the treatment of choice. Expansive laminoplasty offers advantages in terms of maintaining structural stability and achieving satisfactory neural decompression, as in our case.

1. William E. Gordon, Brent Y. Kimball, Adam S. Arthur. “Traumatic lumbar spinal subdural hematoma”. Interdisciplinary neurosurgery journal.2014; 123-127
2. Cooper J, Gillick JL, LaBagnara M, Das K, Hillard VH. “Traumatic Lumbar Subdural Hematoma in the Absence of Intracranial Disease”. World Neurosurg.2016 Jun;90:706.e15-8.
3. Wajima D, Yokota H, Ida Y, Nakase H. “Spinal subdural hematoma associated with traumatic intracranial interhemispheric subdural hematoma”. Neurol Med Chir (Tokyo).2012;52(9):636-9.
4. Mattle H, Sieb JP, Rohner M, Mumenthaler M. Nontraumatic spinal epidural and subdural hematomas. Neurology 1987;37:1351–6.
5. Domenicucci M, Ramieri A, Ciappetta P, Delfini R. Nontraumatic acute spinal

subdural hematoma: report of five cases and review of the literature. J Neurosurg

1999;91:65–73

6. Edelson RN, Chernik NL, Posner JB. Spinal subdural hematomas complicating

lumbar puncture. Arch Neurol 1974;31:134–7.

7. Konitsiotis S, Glantzouni A, Argyropoulou MI, Tsapoga T, Elisaf M, Efremidis SC.Acute spontaneous spinal subdural haematomas in a patient with essential

thrombocythaemia. J Neurol 2003;250:1109–11.

8. Hung KS, Lui CC, Wang CH, Wang CJ, Howng SL.”Traumatic spinal subdural hematoma with spontaneous resolution”. Spine (Phila Pa 1976).2002 Dec 15;27(24):E534-8.
9. Boukobza M, Haddar D, Boissonet M, Merland JJ. Spinal subdural haematoma: a study of three cases. Clin Radiol 2001;56:475–80.
10. Lee JI, Hong SC, Shin HJ, Eoh W, Byun HS, Kim JH. Traumatic spinal subdural hematoma: rapid resolution after repeated lumbar spinal puncture and drainage.J Trauma 1996;40:654–5.
11. Juvonen T, Tervonen O, Ukkola V, Klintrup HE. Widespread posttraumatic spinal subdural hematoma—imaging findings with spontaneous resolution: case report. J Trauma 1994;36:262–4.
12. Braun P, Kazmi K, Nogues-Melendez P, Mas-Estelles F, Aparici-Robles F: MRI findings in spinal subdural and epidural hematomas. Euo J Radiol 64: 119–125, 2007