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Post-operative Hematoma

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When we consider epidural hematomas of the spinal canal,

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far and away the most common is going

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to be secondary to previous surgery.

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And we're talking about in the immediate

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surgical post-op scanning.

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So, it is not uncommon for the neurosurgeons or

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orthopedic surgeons to order a post-op scan in order to

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look at their hardware. And in so doing, to also look for

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epidural hematomas that may be compressing the spinal

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canal. This is a patient who, as you can see,

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has surgical hardware with fusion in the lower thoracic

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region extending to the lumbar region.

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This is part of a complete spine MRI scan.

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If you notice on the T2-weighted scan to the left, you

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have what looks like narrowing of the thecal sac above and

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below what is a collection in the operative bed, and

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this is leading to displacement of the spinal

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cord anteriorly. So here's our spinal cord,

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here's our collection,

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here's that narrowing of the thecal sac.

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And this is quite large in size.

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You'll notice that it is bright on the T2-weighted

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scan, and on the T1-weighted scan, it is dark.

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This darker signal on the T1-weighted scan is

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in part because of the patient's kyphosis,

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which leads to the relevant anatomy being farther

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anterior and away from the surface coil, which is placed

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on the back here and therefore

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you lose signal intensity.

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I'm going to try to win this a little bit better.

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So nonetheless,

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we do are able to see that the spinal cord is being

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displaced anteriorly. On the STIR image,

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you see again bright signal intensity.

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It's got some heterogeneity to it and you can see that

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the spinal cord is being displaced anteriorly,

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the thecal sac is being narrowed, and there may

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even be a little area of spinal cord

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high signal intensity down here at approximately

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the T10-T11 level. And again, at T11-T12.

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So, is this just post-op fluid?

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Is this edema? Is this hematoma?

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Bottom line is that it's compressing the spinal cord.

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And although the signal intensity suggests that

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this is more likely to be post-op edema,

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being dark on T1 and bright on T2. In

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the immediate post-operative setting,

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a lot of times, we can't tell the difference between

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hematoma and just edema. In any case,

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this patient needs to be explored since there

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is cord compression and cord displacement.

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Normally, we would look at the signal intensity and try

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to derive whether or not this was

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secondary to deoxyhemoglobin.

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Deoxyhemoglobin on a T1-weighted scan is dark in signal

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intensity, and on T1-weighted scans would

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be also dark in signal intensity.

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And you can have hemorrhage within the edematous

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post-operative bed. If we look on the STIR image,

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seeing these darker areas anteriorly within this

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collection is worrisome for this being deoxyhemoglobin

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amidst a post-operative edematous collection,

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and again, is worth exploring.

Report

Description

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Spine

Neuroradiology

Musculoskeletal (MSK)

MRI

Iatrogenic

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