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

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.