To describe cases of cervical epidural hematomas associated with spinal manipulation therapy (SMT) of the neck.

Spontaneous spinal epidural hematomas (SSEH) are by definition not associated to trauma. Albeit uncommon, the early recognition of this condition is paramount as it can lead to rapid development of neurological deficits and cause permanent disability.

Case description and review of literature.

63-year-old male presented after sudden onset of fluctuating weakness of both legs and right arm, associated with back pain radiating to his neck. No trauma was reported.  He underwent chiropractic manipulation of his neck two days prior.  His medical history was significant for L4-L5 laminectomy.  Medications included aspirin, but no anticoagulants. 

Neurological exam revealed flaccid paralysis of both lower extremities and right upper extremity.  Deep tendon reflexes and plantar reflex were absent. Within hours he developed a sensory level at T6, urinary incontinence and loss of rectal tone.  Platelets were 215k, aPTT 26 and INR 1.1. CT angiogram head/neck/chest did not show dissections or occlusions. MRI cervicothoracic spine confirmed an epidural hematoma from C2 to T7 causing cord compression, without evidence of AVMs. Urgent laminectomy and evacuation was performed. 

Postoperatively the patient gradually recovered strength and sensation of the extremities. After one week he could walk and was discharged to rehabilitation.  

SSEH after SMT described in the literature had symptoms ranging from headache to quadriparesis. Contributing factors included warfarin use, spinal injection, undiagnosed AVM and pregnancy. Some had evidence of excessive force or inadequate technique used during SMT. Usually onset of symptoms was minutes after SMT.

Although this remains a rare condition, it is vital to raise awareness among health care providers, who should identify, counsel and treat similar patients.