A spinal hemorrhage is bleeding that occurs within the spinal column, either in the tissues surrounding the spinal cord or within the cord itself. This accumulation of blood, known as a hematoma, creates a mass effect that compresses delicate neural structures. Though rare, a spinal hemorrhage constitutes a time-sensitive medical emergency requiring immediate attention. The resulting pressure on the spinal cord or nerve roots can rapidly lead to severe neurological compromise. Swift diagnosis and intervention are necessary to minimize the potential for permanent functional loss.
Defining Spinal Hemorrhage and Its Types
The spinal cord is protected by three layers of membranes called meninges: the dura mater, the arachnoid mater, and the pia mater. These layers define the potential spaces where a hemorrhage can occur. The location of the bleeding dictates the specific type of spinal hemorrhage and its potential impact on the nervous system.
The most frequently encountered location is the epidural space, situated between the dura mater and the bony vertebral canal. An epidural hemorrhage is often associated with the rich internal vertebral venous plexus located within this space. This type of bleed is often contained by the dura, causing compression as it expands.
A spinal subdural hemorrhage occurs in the potential space between the dura and the arachnoid mater. This location is far less common than the epidural space. Bleeding can also occur in the subarachnoid space, which is filled with cerebrospinal fluid (CSF). A spinal subarachnoid hemorrhage typically spreads longitudinally due to the movement of the surrounding CSF.
The most severe form is an intramedullary hemorrhage, or hematomyelia, which involves bleeding directly into the spinal cord tissue itself. This causes immediate disruption and destruction of sensitive neural pathways.
Primary Causes and Risk Factors
Spinal hemorrhages are categorized as either traumatic or non-traumatic, with trauma being the leading cause of bleeding directly into the spinal cord tissue. Significant force from severe falls, motor vehicle accidents, or direct blows can cause structural damage that ruptures surrounding vessels. Non-traumatic, or “spontaneous,” hemorrhages are often linked to underlying medical conditions or therapeutic interventions.
A common non-traumatic cause involves disorders that affect the blood’s ability to clot, known as coagulopathies or bleeding diatheses. Patients receiving anticoagulant or antiplatelet medications, such as warfarin or clopidogrel, are at an increased risk of hemorrhage. These medications inhibit the body’s natural clotting mechanisms, making minor vessel injury a source of significant bleeding.
Vascular malformations represent another major cause, particularly structures like spinal arteriovenous malformations (AVMs) or cavernomas. These are abnormal tangles of blood vessels that have weakened walls, making them prone to rupture. Other predisposing factors include spinal tumors, severe and uncontrolled high blood pressure, and certain invasive procedures.
Iatrogenic causes result from medical intervention, including procedures like lumbar puncture, epidural anesthesia, or spinal surgery. While generally safe, these procedures carry a small risk of injuring a vessel, which can lead to a hematoma, especially in patients with existing risk factors.
Recognizing the Symptoms
The clinical presentation of a spinal hemorrhage is typically acute and progresses rapidly, making prompt recognition a time-sensitive matter. The defining initial symptom is often sudden, excruciating, and localized back or neck pain, sometimes described as a sharp sensation. This pain is localized to the area of the spine where the bleeding is occurring.
Following the onset of pain, patients frequently experience a swift development of neurological deficits due to the compression of the spinal cord or nerve roots. Motor weakness may manifest as hemiparesis, paraparesis, or quadriparesis, involving weakness or paralysis in two or all four limbs. The speed at which this weakness progresses is a critical indicator of the urgency of the situation.
Sensory changes are also common and may include numbness, tingling sensations known as paresthesia, or a distinct loss of sensation below the level of the hemorrhage. A clear sensory level, where normal sensation abruptly transitions to impaired sensation, points directly to the compressed segment of the spinal cord.
A serious sign is the onset of autonomic dysfunction, involving the involuntary nervous system. This may present as difficulty with bladder or bowel control, such as urinary retention or incontinence, indicating pressure on the lower spinal cord or the nerve bundle known as the cauda equina. Any combination of severe pain, rapid weakness, and loss of sphincter control signals a neurosurgical emergency.
Diagnosis and Treatment Options
Confirming a spinal hemorrhage begins with a thorough physical and neurological examination, which helps the clinician localize the level of the spinal cord involvement. The gold standard imaging modality for diagnosing a spinal hemorrhage is Magnetic Resonance Imaging (MRI). MRI provides detailed images of soft tissues, allowing for precise determination of the hemorrhage’s location, size, and the degree of spinal cord compression.
If MRI is contraindicated due to metal implants or unavailable, a Computed Tomography (CT) scan combined with myelography may be used. CT myelography involves injecting contrast dye into the space surrounding the spinal cord to outline the compression caused by the hematoma. Laboratory testing, especially coagulation studies like the International Normalized Ratio (INR), are performed immediately to check for underlying bleeding disorders or medication effects that need to be reversed.
The immediate treatment strategy involves stabilizing the patient and addressing coagulation issues. For patients taking anticoagulants, their effects must be reversed urgently using agents like Vitamin K, fresh frozen plasma, or prothrombin complex concentrates (PCCs). This medical intervention aims to stop the active bleed before it causes further damage.
The definitive treatment for most symptomatic spinal epidural and subdural hematomas is emergent surgical evacuation. This involves a procedure called a laminectomy, where a portion of the vertebral bone is removed to access the hematoma and relieve the pressure on the spinal cord. Surgical decompression is most effective when performed as quickly as possible, ideally within hours of the onset of severe or rapidly progressing neurological deficits. For smaller, stable hematomas in patients with minor or non-progressive symptoms, a conservative management approach involving close monitoring may be attempted. The potential for a good long-term recovery is significantly tied to the speed of diagnosis and the efficacy of surgical intervention in relieving the cord compression.