**2. Adults**

#### **2.1 Demographics and risk factors**

SSEH can affect all adult age groups, but most reported cases are aged between 50 and 80 years [14]. There is no obvious gender association, although pregnancy is an independent risk factor [14]. In most adult patients no known risk factors are identified, but according to the most recent review 19% had hypertension, 14% had cardiovascular disease, 3% had bleeding disorders and 6% had diabetes or obesity [14]. Interestingly, bleeding disorders did not specifically affect a younger population, but as expected by their cumulative medical comorbidities, patients on anticoagulation therapy were generally older. The most common anticoagulants identified in adults with SSEH were Warfarin (43.9%), Aspirin (36.8%) or Clopidogrel (10.5%).

#### **2.2 Clinical presentation**

At presentation, most adults (98%) complain of back and radicular pain [14]. Most haematomas reported in the literature cause spinal canal compression with severe caudal motor (58% Medical Research Council grade 0) and sensory dysfunction (70% American Spinal Injury Association (ASIA) A-C) [14]. In contrast, relatively few patients presented with compression of a nerve root in the neuroforamen, and in these cases most patients (63%) maintain normal or near normal motor (70% MRC grade 4 or 5) and sensory function (63%) [14].

Of concern, up to 15% of adults with SSEH are suspected of having an alternative diagnosis, half of which are thought to be affected by an ischaemic incident for which anticoagulation therapy is considered or administered. The most common diagnoses that SSEH mimic are cerebro-vascular accidents (CVA), myocardial infarctions, spinal tumours and disc prolapses. Thus, clinicians should be aware of this condition and its ability to mimic alternative diagnoses, prior to considering anticoagulation therapy.

#### **2.3 Investigations**

The diagnosis is easily confirmed on cross-sectional imaging, most commonly an MRI scan or CT myelogram. An MRI is preferential as it offers a clear localisation and cause of compression (**Figure 1**). In contrast to a CT which accurately localises compression but is less accurate in determining the underlying cause (**Figure 2**).

In adults most SSEH affect the cervico-thoracic region between C3 and T3. This is attributed to this region being the only area of the spinal canal with a compact continuous epidural venous network [15]. These haematomas can be large and affect up to 28 spinal levels, with the average number of levels affected being 5.4 vertebral levels. Furthermore, although rare, multi-site haematomas can occur, therefore whole spine imaging is advocated.

#### **Figure 1.**

*A T1 (a), STIR (b) and GRE (c) sagittal MRI sequence of a C4–6 SSEH compressing the spinal cord.*

**Figure 2.** *A sagittal non-contrast CT scan of a C2–6 SSEH compressing the spinal cord.*

#### **2.4 Treatment**

The gold standard of treatment for patients with SSEH and neurological dysfunction is expeditious surgical decompression. However, in patients with no neurology or with improving neurology, non-operative treatment with close neurological monitoring is the treatment of choice. There is no evidence to support operative intervention based on the presence of back pain or the size of the haematoma, rather, neurological dysfunction guides the decision to operatively intervene. In patients with a bleeding tendency, systemic pro-coagulant therapy should also be used.

With this approach to treatment, 85% of patients can be expected to make a complete or partial recovery [14]. This recovery is usually rapid, but in some patients this may take a number of years, which results in a reported average time to recovery of 52.4 days [14]. These outcomes are unrelated to patient age, sex, haematoma size or location.

According to the current literature, 5% of patients worsen their neurological function despite treatment and the mortality rate is 3.5% [14]. The most common cause of death is cardiac disease rather than neurological dysfunction from SSEH.

#### **3. Pregnancy**

Unlike in the general population, SSEH carry the additional concern for the well-being of the foetus. Thus, the goal of treatment is to restore normal neurological function to the mother, but with minimal risk to the foetus [13].

Like the general adult population, the treatment options include surgical decompression, but this carries surgical and anaesthetic risks; radiological aspiration with or without embolisation, but this too carries anaesthetic risks, rarely evacuates the haematoma completely, risks neuro-vascular injury and exposes the mother and foetus to radiation; or chemotherapy with steroids and/or coagulation therapy, but this fails to remove the compressive effects of the haematoma and requires systemic administration of the drug. Thus, the treatment approach is complex and requires consideration of both the mother and foetus.

#### **3.1 Demographics and risk factors**

In pregnancy, an increased blood volume and pressure predisposes to rupture of vascular walls and therefore SSEH [16]. Thus, it is rare for SSEH to occur in the first trimester but the risk increases with the duration of pregnancy with an average gestational age of 34.3 weeks being reported in the literature [17]. No cases have been reported during labour, although some have been reported in the days and weeks following delivery, which suggests that the pregnancy-induced dilation of epidural vessels, rather than the mechanical straining of labour, is the predominant cause of SSEH in pregnancy.

There does not appear to be a relationship between the gravid status and the risk of SSEH [17]. Furthermore, most patients do not have any known risk factors, although pre-eclampsia has been reported in two cases. No pregnant patients with SSEH have been reported to be on anticoagulation therapy [17].

#### **3.2 Clinical presentation**

Like the general population, patients present with back or neck pain, usually with neurological dysfunction [17]. Within the English literature, most patients have severe spinal cord dysfunction with gait disturbance, caudal weakness and sensory disturbance. Only one reported patient has presented without neurological dysfunction [17].

#### **3.3 Investigations**

In pregnancy, limited radiation exposure to the foetus is necessary, thus an MRI is the investigation of choice. No patients have been reported to have had a CT scan, although, if an MRI is not possible and the diagnosis is critical then a CT or CT myelogram is necessary with protection of the pelvis [7].

Like the general adult population, the typical location of the SSEH is the cervico-thoracic region [17]. The size of the haematoma has been reported to span two to six spinal levels [17].
