Open Journal of Clinical Diagnostics, 2011, 1, 5-8 OJCD
doi:10.4236/ojcd.12002 Published Online September 2011 (
Published Online ****** 2011 in SciRes.
Spontaneous Spinal Subdural Hematoma Developed After
Weightlifting: A case Report and Review of Literature
JiEun Park, SooMi Lim, Jeong Hyun Yoo*
Department of Radiology, Mokdong Hospital, EwhaWomans University School of Medicine, Seoul, Korea.
Email: *
Received 5 July 2011; revised 3 August 2011; accepted 23 August 2011.
Spontaneous spinal subdural hematoma is a rare
disease. Several predisposing factors are reported
including impaired clotting due to therapeutic anti-
coagulation or hematologic disorder, vascular anom-
aly, intraspinal tumor, and iatrogenic causes such as
lumbar puncture or spinal anesthesia.We report a
rare case of spontaneous spinal subdural hematoma
developed after weightlifting in a healthy young man
treated with conservative treatment.
Keywords: Spinal Hematoma; Spinal Subdural Hema-
toma; Spontaneous Subdural Hematoma
Spontaneous spinal subdural hematoma (SSDH) is a rare
disease entity with little known pathogenesis. It is
known to be associated with several predispo sing factor s
including impaired clotting due to therapeutic antico-
agulation or hematologic disorder, vascular anomaly, in-
traspinal tumor, and iatrogenic causes such as lumbar
puncture or spinal anesthesia. There is an ongoing con-
troversy on whether surgical or conservative treatment
should be preferred in SSDHs. Here, we report a case of
spontaneous SSDH with concomitant intracranial hy-
potension developed after weightlifting, without un-
derlying predisposting factors and treated with conserva-
tive treatment.
A 38-year-old man was referred to the emergency room
with severe headache and upper back pain. A month be-
fore, he had a sudden onset upper back pain while lifting
weights and was subsequently treated with physical
therapy at a local clinic. He had been weight lifting on
regular basis, twice a week for about 3 months so far.
There was no history of direct trauma to the upper neck.
The pain was not subsided, and new symptoms of head-
ache with vomiting aroused several hours before he vis-
ited the emergency room. No neurologic abnormalities
were found. Brain computed tomography(CT) was
within normal limits. However, brain MRI showed dif-
fuse dural thickening and intense meningeal enhance-
ment indicating intracranial hypotension(Figure 1).
Figure 1. FLAIR axial image shows diffuse
dural thickening (a) and enhanced axial image
shows diffusepachymeningeal enhancement
J. Park et al. / Open Journal of Clinical Diagnostics 1 (2011) 5-8
Copyright © 2011 SciRes. OJCD
On admission, his coagulation profiles including
platelet count, prothrombin time, and partial throm-
boplastin time were within normal range. There was no
previous history of anticoagulant therapy or hema-
tologic disease, and he had been in good health. He did
not take any medication.Cervical spine MRI revealed a
well-demarcated ventral subdural hematoma ranging
from C6 to T5, mildly compressing the cervical spinal
cord (Figure 2). The T1-weighted MR images of the
hematoma showedhigh and low signal intensities, and
the T2-weighted image showed a mixed pattern of low-
and dark signal intensities. Based on these findings, an
acute to early subacute stage of spinal SDH was diag-
The patient was prescribed with IV analgesics to re-
duce headache, absolute bed rest to prevent intracranial
hypotension, and IV steroids to prevent intramedullary
edema. Initial IV steroids were gradually tapered out a
week later, as he did not show any neurologic deficit on
subsequent exams. MR images at 2 weeks of conserva-
tive treatment showed hematoma resorption with im-
provement of compressive myelopathy. Follow up MRI
at 10 weeks showed complete resolution of the hema-
toma without residual symptom (Figure 3).
Spontaneous spinal subdural hematoma (SSDH) is a
rare disease entity first described by Shiller and co-
workers more than 60 years ago [1]. Several predis-
posing factors are reported to have caused this, in-
cluding impaired clotting due to therapeutic antico-
agulation or hematologic disorder, vascular anomaly,
intraspinal tumor, and iatrogenic causes such as lum-
bar puncture or spinal anesthesia. However, the
pathogenesis of spontaneous SSDHs is little under-
(a) (b)
(c) (d)
Figure 2. Spine MR shows spinal subdural hemorrhage anterior to the
spinal cord from the C6 to L5 level with iso- and low signal intensity on
T2-weighted image (a, c) and high and low- signal intensity on
T1-weighted (b,d). Axial image scanned at T2 level reveals the lesion
compressing the s p i nal c ord .
J. Park et al. / Open Journal of Clinical Diagnostics 1 (2011) 5-8
Copyright © 2011 SciRes. OJCD
a b
Figure 3. Follow up MRI at 10 weeks. Sagittal T2-weighted (a) and T1-
weighted (b) MRI shows resolution of the hematoma.
A commonly accepted hypothesis is the rupture of
valvelessradiculomedullary veins that cross the subdural
and subarachnoid spaces causing spontaneous SSDHs [2,
3].Additionally, rupture of the small extra-arachnoidal
vessels located on the inner surface of the dura also re-
sults in subdural hematomas [4]. Rader et al. hypothe-
sized that sudden increase in this intravascular pressure
in the spinal subdural space causes disparity between
intravascular and extravascular pressure resulting in the
tearing of the spinal vessels [5].
Another hypothesis about the origin of spontaneous
SSDHs relates to the anatomical structure of the dura
mater. The dura mater has two layers, the strong external
layer and the fairly weaker inner layer, the latter of
which is susceptible to injury. Minor trauma causes tear
of the inner dura, and damage to theradiculomedullary
veins which cross it. Hung et al. hypothesized that the
rising of intracranial pressure increasesthe shearing force
between spinal subdural and subarachnoid spaces so that
the inner dura may tear and bleed [6].
As far as I concerned, it is the rare case report that
weightlifting caused spontaneous spinal subdural hema-
toma. We presumed the excessive Valsalva maneuver
developed during the weightlifting that caused increase-
ing the intravascular pressure with/without direct minor
trauma to the spinal inner dura, whichfinally resulted in
spontaneous spinal subdural hematomas. In this patient,
SSDH was also accompanied with intracranial hypoten-
sion. This intracranial hypotension associated with
SSDH may be a result of CSF leakage at the site of the
hemorrhage, although a reverse hypothesis can be possi-
ble that intracranial hypotension induces cerebro-spinal
hypotension leading to SSDH.
SSDH occursmost often in the thoracic level with the
initial symptomsof sudden onset back pain radiating
limb or trunk. Neurologic deficits are also observed with
variable degrees of motor, sensory, and autonomic dis-
turbance, but the symptom onset to neurologic deficit
shows variable time interval. If the patient with antico-
agulant therapy history have abrupt onset of spinal cord
compressing symptom or sign, SSDH must be consid-
ered. Prompt diagnostic work-up required for the correct
diagnosis. MRI is the preferred method showing usually
ventral located space-occupying hematoma.
Our patient has no history such as coagulation therapy
or other presumptive history suggestive SSDH. Although
the initial symptom was the abrupt posterior neck pain,
the initial symptomwas skipped by the patients.If the
diagnosis was early, spinal MRI would show hyperacute
or acute stage of SSDH, but our case showed delayed
hematoma with subacutestage.
There is an ongoing controversy on whether surgical
or conservative treatment should be preferred in SSDHs.
As there is no underlying pathology to undergone sur-
gery, therapy is targeted to decrease the hematoma in
spontaneous SSDHs. Several authors proposed that con-
servative management may be indicated when the sever-
ity of neurologic symptoms is less than grade D or better
on the Frankel grading scale [10-12]. Since the patient
did not show definite neurologic deficit, conservative
treatment was the mode of choice, and complete resolu-
tion of the hematoma was obtained. We agree that
prompt surgical evacuation should be considered to pa-
tients with severe neurologic deficit, before irreversible
damage is done to the spinal cord. However, it is rec-
ommended to consider conservative management when
J. Park et al. / Open Journal of Clinical Diagnostics 1 (2011) 5-8
Copyright © 2011 SciRes. OJCD
neurologic symptoms are mild or the symptoms improve
quickly to the treatment of spinal edema.
Several predisposing factors are reported to have caused
this spontaneous spinal subdural hematoma (SSDH).
The weightlifting practical exercise can be a one of
cause of developing the spontaneous SSDH which can
associate with intracranial hypotension.
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