Hematoma epidural espinhal pós-traumático agudo: um relato de caso

Abstract

Introduction: Spinal trauma can lead to serious complications. We report a case of trauma to the cervicothoracic spine, with common complications, such as fractured vertebrae and bilateral hemopneumothorax. However, another rare complication stood out, the Spinal Epidural Hematoma (SHE). An accumulation of blood in the epidural space that mechanically compressed the spinal cord. This compression commonly causes temporary or permanent neurological deficits. The most effective treatment is surgical decompression, with evacuation of the clot. Objective: Describe a case of post-traumatic SHE, with its outcome, through the analysis of medical records and studies in the literature. Case-report: We report the case of a 59-year-old male patient with post-traumatic spinal epidural hematoma in the thoracic spine, with late neurological deficit, paraplegia and anesthesia at the T6 dermatome level. Decompressive T3-T4 laminectomy was performed, followed by a flavectomy that showed a large spinal epidural hematoma, occupying 2/3 of the spinal canal. After surgery, there was complete improvement in anesthesia, persistence of paraplegia, as well as loss of control of the sphincters. Conclusion: SHE is a rare event, where early diagnosis of hematoma and correction with the decompressive laminectomy technique guarantees the patient a better neurological prognosis.