Thoracic spinal subdural hematoma after spinal cord stimulation trial: a case report

Background: Spinal subdural hematoma (SSDH) is a rare but potentially serious condition characterized by a compressive accumulation of blood within the thecal sac. It may result from trauma, surgery, or underlying vascular abnormalities, often associated with anticoagulant use. In this case, SSDH was diagnosed post-implantation of a spinal cord stimulation (SCS). Current estimates suggest that a neuraxial (including epidural) hematoma following SCS occurs in about 0.32% of cases, with no reported sub/intradural pathology from uncomplicated SCS procedures. Case Description: We report a case of SSDH in a 78-year-old male, diagnosed after a percutaneous dorsal column stimulator trial for chronic postherpetic thoracic neuralgia. The patient presented with days of weakness and gait instability, 1 month post-SCS trial. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed an intrathecal lower lumbar T1/short tau inversion recovery (STIR) signal, fluid-fluid level, and cauda equina enhancement suggestive of a subarachnoid hemorrhage, as well as a well-circumscribed, compressive T2-T3 subdural collection consistent with hematoma, later confirmed by pathology. Notably, bleeding occurred in the absence of coagulopathy or dural puncture. A spinal angiogram ruled out vascular lesions. The patient underwent a successful laminectomy and intradural hematoma evacuation, resulting in gradual functional recovery. Conclusions: To our knowledge, this is the first reported case of SSDH following uncomplicated SCS. Possible etiology includes epidural trauma from SCS lead placement, causing shear stress, leading to an angiogenic/inflammatory response with eventual neomembrane formation and space-occupying hematoma responsible for the subacute myelopathic presentation. Prompt diagnosis and treatment are crucial to prevent permanent neurological damage due to spinal compression.