Case summary

In this report, Zeng and colleagues describe an 82-year-old Chinese woman with severe left L5 radiculopathy and neurogenic claudication caused by L4–L5 degenerative lumbar spinal stenosis. Conservative therapies including physiotherapy and medication had failed, and the patient underwent unilateral biportal endoscopic (UBE) decompression.

The surgery was technically successful, with minimal blood loss (25 mL), preserved facet integrity, and immediate improvement in radicular symptoms. Early postoperative recovery was uneventful, with independent ambulation and no neurological deficits.

Unexpectedly, postoperative day 3 CT imaging demonstrated extensive multisegmental epidural hematoma extending from T12 to L4. The imaging findings on page 3 show longitudinal hematoma spread across multiple spinal levels without evidence of cord injury or progressive compression. Despite the dramatic radiographic appearance, serial neurological examinations demonstrated preserved motor function, intact sensation, and no bowel or bladder dysfunction (ASIA grade E).

Because the patient remained neurologically stable, the team pursued conservative management with close monitoring, rehabilitation restriction, serial imaging, and thrombosis prophylaxis without anticoagulation. The authors discuss several possible contributors to hematoma formation, including epidural venous bleeding, drainage management, blood pressure fluctuations, vascular fragility associated with advanced age, and postoperative hemodynamic changes unique to endoscopic spine surgery.

Follow-up MRI at 50 days demonstrated complete hematoma resolution with normalized thecal sac morphology. At 3-month and 6-month follow-up, the patient had minimal residual pain, preserved neurologic function, and no evidence of recurrent hematoma or cauda equina dysfunction.

This case is particularly notable because most postoperative spinal epidural hematomas presenting with neurological deterioration require emergent decompression within 6 hours to prevent permanent deficits. Here, however, a massive multilevel hematoma resolved completely without surgery, challenging assumptions regarding mandatory reoperation in carefully selected asymptomatic patients.

Why this case matters

• Describes an exceptionally rare five-segment postoperative epidural hematoma
• Demonstrates successful conservative management despite extensive imaging abnormalities
• Highlights the importance of neurological examination over imaging appearance alone
• Reinforces careful postoperative surveillance after UBE spine surgery
• Provides insight into pressure dynamics and bleeding mechanisms unique to minimally invasive endoscopic decompression

Clinical Take-Home Message

Extensive postoperative spinal epidural hematoma does not always mandate emergent surgical evacuation; in neurologically intact patients, carefully monitored conservative management with serial imaging and close neurological surveillance may achieve complete recovery.

Question:

What was the key factor supporting conservative rather than surgical management in this case?

A. Minimal hematoma size
B. Presence of severe canal compromise
C. Preserved neurological function without cauda equina syndrome
D. Early anticoagulation therapy

Correct answer: C. Preserved neurological function without cauda equina syndrome

Explanation:
Despite dramatic multilevel epidural hematoma extending from T12 to L4, the patient maintained intact motor, sensory, bladder, and bowel function (ASIA grade E). The absence of neurological deterioration allowed safe conservative management with serial monitoring.

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