eMedicine Specialties > Neurology > Neurological Emergencies

Spinal Cord Hemorrhage

Author: Richard M Zweifler, MD, Chief of Neurology, Sentara Healthcare, Norfolk, VA
Contributor Information and Disclosures

Updated: Dec 4, 2008

Introduction

Background

Hemorrhage affecting the spinal cord is rare. It most commonly is caused by trauma, vascular malformations, or bleeding diatheses and can be intramedullary, subarachnoid, subdural, or epidural. Onset is usually sudden and painful, causing myelopathic signs and symptoms.

Pathophysiology

Hematomyelia is caused by bleeding within the substance of the spinal cord. The blood tends to dissect longitudinally above and below the hemorrhage, disrupting gray matter more than white matter. Spinal subarachnoid hemorrhage (SAH) may cause symptoms due to blood in the subarachnoid space or blood dissecting into the spinal cord or along nerve root sheaths. Spinal epidural hemorrhage (EDH) and subdural hemorrhage (SDH) cause compressive symptoms due to hematomas in these spaces.

Frequency

United States

Hemorrhage affecting the spinal cord is rare. Spinal subarachnoid hemorrhage accounts for less than 1% of all subarachnoid hemorrhages. Spinal epidural hemorrhage occurs at least 4 times more commonly than spinal subdural hemorrhage.

Mortality/Morbidity

Spinal hemorrhage can lead to irreversible myelopathy (including conus medullaris and cauda equina syndromes) and/or radiculopathy.

Sex

The incidence of hematomyelia, spinal subarachnoid hemorrhage, and spinal epidural hemorrhage is higher in males than in females. Spinal subdural hemorrhage is more common in women (female-to-male ratio is 2:1).

Age

Spinal epidural hemorrhage has a bimodal distribution, with peaks during childhood and the fifth and sixth decades of life. Spinal epidural hemorrhage is most common in the cervical region in children and in the thoracic and lumbar regions in adults. Spinal subdural hemorrhage predominates in the sixth decade.

Clinical

History

  • Intramedullary hemorrhage
    • Sudden, severe, localized back pain with or without radicular pain
    • Hemiparesis, paraparesis, or quadriparesis
    • Sensory loss below the lesion
    • Loss of sphincter control
  • Spinal subarachnoid hemorrhage
    • Sudden, severe, localized back pain with or without radicular pain
    • Headache
    • Meningismus
  • Spinal epidural hemorrhage and spinal subdural hemorrhage
    • Sudden, severe, localized back pain with or without radicular pain
    • Hemiparesis, paraparesis, or quadriparesis
    • Sensory loss below lesion
    • Loss of sphincter control

Physical

  • Intramedullary hemorrhage - Myelopathy (eg, Brown-Séquard syndrome, central cord syndrome, transection syndrome, conus medullaris syndrome) with or without radiculopathy
  • Spinal subarachnoid hemorrhage
    • Myelopathy (eg, Brown-Séquard syndrome, transection syndrome, conus medullaris syndrome, cauda equina syndrome) with or without radiculopathy
    • Cranial neuropathies
    • Papilledema
    • May have cutaneous angioma or bruit over the spine
  • Spinal epidural hemorrhage and spinal subdural hemorrhage - Myelopathy (eg, Brown-Séquard syndrome, transection syndrome, conus medullaris syndrome, cauda equina syndrome) with or without radiculopathy

Causes

  • Intramedullary hemorrhage
    • Trauma
    • Vascular malformations
    • Bleeding diatheses
    • Anticoagulants
    • Hemorrhage into tumor
    • Venous infarction
  • Spinal subarachnoid hemorrhage
    • Spinal angioma
    • Spinal artery aneurysm
    • Intracranial aneurysm
    • Bleeding diatheses
    • Anticoagulants
    • Polyarteritis nodosa
    • Hemorrhage into tumor
    • Trauma
    • Lumbar puncture
  • Spinal epidural hemorrhage
    • Spontaneous
    • Trauma
    • Liver disease with portal hypertension
    • Bleeding diatheses
    • Lumbar puncture
    • Epidural anesthesia
    • Epidural vascular malformation
  • Spinal subdural hemorrhage
    • Bleeding diatheses
    • Anticoagulants
    • Trauma
    • Lumbar puncture
    • Vascular malformations
    • Spinal surgery
    • Spontaneous

More on Spinal Cord Hemorrhage

Overview: Spinal Cord Hemorrhage
Differential Diagnoses & Workup: Spinal Cord Hemorrhage
Treatment & Medication: Spinal Cord Hemorrhage
Follow-up: Spinal Cord Hemorrhage
Multimedia: Spinal Cord Hemorrhage
References
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References

  1. Aminoff MJ. Vascular disorders of the spinal cord. In: Davidoff RA, ed. Handbook of the Spinal Cord. New York: Marcel Dekker; 1987:259-97.

  2. Barth A, Bougousslavsky J, Caplan LR. Spinal stroke syndromes. In: Barth A, Caplan LR, eds. Stroke Syndromes. 1995. New York: Cambridge University; 395-402.

  3. Geldmacher DS, Bowen BC. Spinal cord vascular disease. In: Bradley WG, Daroff RB, Fenichel GM, Marsden CD, eds. Neurology in Clinical Practice Principles of Diagnosis and Management. 4th ed. Philadelphia, Pa: Butterworth-Heimann; 2004:1313-22.

  4. Karavelis A, Foroglou G, Petsanas A, Zarampoukas T. Spinal cord dysfunction caused by non-traumatic hematomyelia. Spinal Cord. May 1996;34(5):268-71. [Medline].

  5. Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. Aug 1983;20(2):133-7. [Medline].

  6. Toole JF. Spinal cord vascular anatomy and diseases. In: Toole JF, ed. Cerebrovascular Disorders. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1990:519-34.

  7. Weisberg LA. Vascular diseases of the spinal cord. In: Rowland LP, ed. Merritt's Textbook of Neurology. 10th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2001:271.

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Further Reading

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Keywords

spinal cord hemorrhage, hematomyelia, spinal subarachnoid hemorrhage, SAH, spinal epidural hemorrhage, EDH, subdural hemorrhage, SDH, subarachnoid space, bleeding in the spinal cord, intramedullary hemorrhage, spinal angioma

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Contributor Information and Disclosures

Author

Richard M Zweifler, MD, Chief of Neurology, Sentara Healthcare, Norfolk, VA
Richard M Zweifler, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Stroke Association, Royal Society of Medicine, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Rodrigo O Kuljis, MD, Esther Lichtenstein Professor of Psychiatry and Neurology, Director, Division of Cognitive and Behavioral Neurology, Department of Neurology, University of Miami School of Medicine
Rodrigo O Kuljis, MD is a member of the following medical societies: American Academy of Neurology and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Concentric Medical None Review panel membership; Northstar Neuroscience  Review panel membership; ev3 Consulting fee Review panel membership

 
 
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