Extensive thoracic spontaneous epidural hematoma presenting with position-induced transient paraplegia: successful conservative management in the resource limited settings

Spontaneous spinal epidural hematoma (SSEH) is a rare condition with an estimated incidence of 0.1 per 100,000 individuals. It is usually characterized by sudden spinal pain followed by rapidly progressive neurological deficits. Surgical treatment is generally indicated if a patient presents with neurological deficits. We report a case of SSEH presenting with neurological deficits relieved after position change, recovering without surgery. The patient was a 73-year-old woman developed sudden, severe pain in the neck, back, lumbar region, and abdomen while sitting after meals. Upon arrival at the emergency department, her vital signs were stable except for hypertension. The patient was placed supine on a stretcher and became agitated because of back pain, but no motor or sensory symptoms were noted in the extremities. Pain initially improved with acetaminophen but recurred, requiring diclofenac. When attempting to sit again, complete motor and sensory deficits were noted in both lower limbs extending from the femur to the soles of the feet (the trunk was not assessed). Lower limbs muscle strength was 1/1 by Manual Muscle Test. Perineal sensory deficits and incontinence were present, leading to a diagnosis of bladder and bowel dysfunction (ASIA Grade A). Imaging revealed an extensive posterior epidural hematoma from C6 to Th12 with maximal cord compression at Th10–12. No coagulopathy or vascular malformations were observed. The hospital was unable to provide emergency surgical decompression because of limited medical resources, including the unavailability of an on-call spine surgeon and refusal of the transfer request. The patient was managed conservatively with analgesia, blood pressure control, and hemostatic agents. Motor function recovered fully, and she was discharged independently on day 13 with only mild residual sensory impairment. This case demonstrates a unique position-induced course; symptoms improved when supine and worsened while sitting. Treatment of SSEH is generally initiated once neurological symptoms appear. A case report described lumbar SSEH with position-induced symptoms; however, it was the opposite of the present case. This discrepancy reflects differences in position related spinal alignment. Lumbar lordosis decreases while sitting, expanding the canal, whereas thoracic kyphosis flattens when supine and increases while seated, narrowing the canal. In this patient, maximal compression at Th10–12 was relieved when supine but exacerbated when sitting. In this case, conservative treatment was selected due to resource limitations, including the lack of an on-call spine surgeon and refusal of the transfer request. This approach ultimately resulted in the most favorable therapeutic outcome. When rapid improvement in position-induced symptoms is observed, conservative treatment may be a better option. These findings emphasize that SSEH presentation depends not only on hematoma size but also on lesion location and posture-related mechanics.