A 28-year-old Chinese male with no past medical history first presented to the emergency department (ED) with sudden onset neck pain radiating to both shoulders and the right lower limb. He had a pain score of 10 out of 10. This was associated with numbness over bilateral upper limbs and the right lower limb. He stated that he does regular weightlifting at the gym and worked as a cabin crew though he had not flown in the preceding year due to the covid pandemic. He was not known to be taking any supplements or blood thinners. There was no preceding trauma. He had no fever or photophobia. He had no headache, giddiness, nausea, or vomiting. There was also no urinary or bowel incontinence.
On physical examination, the patient was ambulant. He localized his pain to the paravertebral region and bilateral shoulders with no midline spinal tenderness. His sensation and power were full on all four limbs. Cranial nerve and cerebellar examination were normal. Lhermitte’s sign was positive with radiating pain to the right upper limb. Hoffmann’s was negative. The patient declined a digital rectal examination.
X-ray cervical spine was normal. Parenteral analgesia was administered with relief of pain, and he was subsequently discharged.
He re-attended two days later in view of neck pain and this was associated with dyspnea and generalized chest pain. He had fallen onto his buttocks when standing up due to right sided upper and lower limb weakness, which started 9 hours before he presented to the ED. His symptom of left upper limb numbness had improved since the first ED visit. He remained dually continent and there was still no headache, vision changes or speech problems. He reported pain over the right upper and lower limbs with a pain score of 8.
On physical examination, there was tenderness over the lower cervical and upper thoracic region. On the Medical Research Council’s (MRC) scale of 0 to 5, his power was 5 for the left upper and lower limbs, and 4 for the right upper and lower limb. Digital rectal examination revealed no abnormalities.
In view of his neurological symptoms coupled with the history of chest pain and dyspnea, he underwent a computed tomography scan of the brain and aortogram. These were reported as normal, with no large ischemic stroke or intracranial hemorrhage or aortic dissection noted.
Seven hours into the ED visit, he reported resolution of his neck pain with some improvement in the power of his right upper limb but also noted deterioration of the power of the right lower limb. He was reviewed by the neurosurgery team in the ED, and their reassessment revealed power 3 for right C5, C7; 4 for right C6, C8 and T1. The power was 2 over the right lower limb. The power was 5 over the left upper and lower limb. Sensation and proprioception were preserved on all four limbs. There was subtle hyper-reflexia in all 4 limbs. Plantar reflexes were down going bilaterally. Pulses were well felt in all four limbs. Heart, lungs and abdominal examination remained normal.
The neurosurgery team suggested for the patient to be admitted under the acute stroke unit in view of right hemiparesis, with plans for magnetic resonance imaging of the brain and spine.
Progress inpatient
His power improved to 4 over his right upper limb and right lower limb by the time he was admitted to the general ward, about 24 hours from the time of onset of symptoms.
Magnetic resonance imaging of the brain and whole spine was performed inpatient on the next day (Figure 1 & 2).
Magnetic resonance imaging of the brain showed no acute infarct or intracranial haemorrhage. Magnetic resonance imaging of the whole spine showed a solitary 3 x 1.9 x 0.8 centimetre extramedullary, extradural lenticular lesion occupying the C5 to C6 spinal canal posteriorly resulting in significant compression of the underlying cervical cord. The non-enhancing lesion showed T1-hyperintensities and susceptibility, and subtle T2-hyperintensities. Bony alignment was preserved and there was no disc bulge or herniation. The rest of the thoracic and lumbar spine were unremarkable. Overall findings were consistent with an acute cervical spinal epidural hematoma, likely spontaneous.
The patient’s care was taken over by the neurosurgery team. He was counselled for early surgery for spinal cord decompression. However, in view of the significant improvement of his neurological status since initial presentation, the patient was not keen for surgery. He was conservatively managed and had full resolution of right sided weakness to power 5 on day 3 of admission, and resolution of numbness on day 5 of admission. He was also given weaning doses of intravenous to oral dexamethasone. A repeat magnetic resonance imaging of the cervical spine 14 days later showed significant interval decrease in size of the spontaneous posterior epidural hematoma at C5 to C6 (now measuring 2.3 x 0.2cm), with no spinal canal narrowing or cord compression and no new hematoma.
The patient was advised to undergo spinal digital subtraction angiography (DSA) to evaluate for possible arterio-venous malformation, but he declined, as he was not keen for an invasive procedure.
He also developed unexplained bruising over his limbs on day 8 of admission. Hematological workup for bleeding disorders including platelet, coagulation profile, factor assays, von Willebrand and myeloma panel were unremarkable.
The patient was discharged on day 14 of admission and was reviewed in the neurosurgery clinic 3 weeks after discharge. He remained well with power 5 over all four limbs.