Subacute spinal subdural hematoma managed by a late lumbar decompression – a case report and literature review

Bartłomiej Pala, Wojciech Andrusewicz, Elżbieta Włodarczyk, Tomasz Pala, Tomasz Klepinowski, Leszek Sagan


Introduction: Spinal subdural hematoma is a rare condition among patients with neurosurgical traumas and so it is a real challenge to establish the correct preoperative diagnosis. Elevated levels of coagulation parameters are their most significant risk factors and occasionally constitute a contraindication for emergent surgery. Our study addresses the subject of the aftermath of postponing the cauda equina decompression. In this report, we describe a case of a 72-year-old obese man who presented with sharp iliolumbar pain and progressive paraparesis. Clinical examination revealed bilaterally decreased deep tendon reflexes, positive straight leg raise sign on both sides, dysaesthesia, and urinary incontinence. Imaging studies showed a mass filling almost the entire spinal canal at the L3/4 level. The surgery had to be postponed due to the excessively high international normalized ratio. The coagulation system was stabilized on the 5th day of hospitalization, hence the L2-L3-L4 laminectomy was performed. A subdural hematoma was visualized after exposing the meningeal sac. After thorough removal of the lesion and subsequent neurorehabilitation, the patient’s neurological functions improved; however, urinary incontinence symptoms remained.
Conclusions: Our unique case report shows potential problems with decision-making regarding the timing of the surgery. Although early decompression is characterized by the best outcome, surgeons are obliged to take into account several factors such as dysregulated coagulation system and if necessary, delay the surgery for the benefit of the patient.


spinal subdural hematoma; early lumbar decompression; late lumbar decompression; coagulation system

Full Text:



de Beer MH, Eysink Smeets MM, Koppen H. Spontaneous spinal subdural hematoma. Neurologist 2017;22(1):34-9.

Kloc W, Iwaniukowicz A, Imieliński BL. Spontaneous chronic spinal epidural haematoma in a 14-year-old boy. Case report. Neurol Neurochir Pol 1992;26(5):733-8.

Vastani A, Mirza AB, Lavrador JP, Boardman TM, Khan MF, Malik I, et al. Risk factor analysis and surgical outcomes of acute spontaneous spinal subdural hematoma. An institutional experience of four cases and literature review. World Neurosurg 2021;146:e384-97.

Wilson JR, Tetreault LA, Kwon BK, Arnold PM, Mroz TE, Shaffrey C, et al. Timing of decompression in patients with acute spinal cord injury: a systematic review. Global Spine J 2017;7(3 Suppl):95S-115S. doi: 101177/2192568217701716.

Luo D, Ji C, Xu H, Feng H, Zhang H, Li K. Intradural disc herniation at L4/5 level causing Cauda equina syndrome: A case report. Medicine (Baltimore) 2020;99(7):e19025.

Yang NR, Kim SJ, Cho YJ, Cho DS. Spontaneous resolution of nontraumatic acute spinal subdural hematoma. J Korean Neurosurg Soc 2011;50(3):268-70.

Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol 2007;64(1):119-25.

Post MJ, Becerra JL, Madsen PW, Puckett W, Quencer RM, Bunge RP, et al. Acute spinal subdural hematoma: MR and CT findings with pathologic correlates. AJNR Am J Neuroradiol 1994;15(10):1895-905.

Schröer RH. Antithrombotic potential of pentoxifylline. A hemorheologically active drug. Angiology 1985;36(6):387-98. doi: 101177/000331978503600608.

Gorczyca I, Wożakowska-Kapłon B. Mój pacjent leczony sulodeksydem – kiedy i dlaczego stosuję? Folia Cardiol 2017;12(6):580-8.

Taj Eldin IM, Elmutalib MA, Hiba A, Hiba F, Thowiba S, Hamedelniel EI. An in vitro anticoagulant effect of aqueous extract of ginger (Zingiber officinale) rhizomes in blood samples of normal individuals. Am J Res Communication 2016;4(1):113-21.

Hogan WB, Kuris EO, Durand WM, Eltorai AEM, Daniels AH. Timing of surgical decompression for Cauda equina syndrome. World Neurosurg 2019;132:e732-8.

Heyes G, Jones M, Verzin E, McLorinan G, Darwish N, Eames N. Influence of timing of surgery on Cauda equina syndrome: Outcomes at a national spinal centre. J Orthop 2018;15(1):210-5.

Lai XW, Li W, Wang JX, Zhang HJ, Peng HM, Yang DH. Delayed decompression for cauda equina syndrome secondary to lumbar disc herniation: long-term follow-up results. J South Med Univ 2017;37(9):1143-8.

Seidel H, Bhattacharjee S, Pirkle S, Shi L, Strelzow J, Lee M, et al. Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome. Spine J 2021;21(5):803-9.

Young EY, Ahmadinia K, Bajwa N, Ahn NU. Does chronic warfarin cause increased blood loss and transfusion during lumbar spinal surgery? Spine J 2013;13(10):1253-8.


Copyright (c) 2022 Bartłomiej Pala

License URL: