Spontaneous Cervical Epidural Hematoma Presenting as Brown-Sequard Syndrome Following Repetitive Korean Traditional Deep Bows
A 65-year-old man (height, 168 cm; weight, 77 kg; body mass index, 27.3 kg/m2) developed a sudden onset of interscapular pain and motor weakness in the left extremities thereafter. He did not complain of any speech impediments, facial palsy or mental change. He had a history of hypertension and type II diabetes mellitus and he was on regular medical treatment for 5 years. He did not take any medications that could affect blood coagulations profiles, like antiplatelet agents. He also underwent nephrectomy and cholecystectomy a few decades ago. Before the onset of symptoms, he made more than two thousand Korean traditional deep bows for three days at his mother's funeral. Right after the last deep bow, he complained of sudden neck and interscapular pain. Brain computed tomography was checked at a local hospital and it showed no definite abnormalities. He received thrombolytic therapy under the impression of acute cerebral infarction. However, motor weakness of the left extremities became aggravated. After being transferred to our hospital, diffusion weighted magnetic resonance imaging (MRI) of the brain was performed, which revealed no evidence of acute cerebral infarction. Laboratory findings including complete blood count, coagulation profiles, and biochemistry profiles were unremarkable. A cervical spine MRI was performed for the evaluation of myelopathy and it displayed a longitudinal cervical epidural hematoma extending from the C2 to C6 vertebrae with a compression of the spinal cord (). He underwent left C3 to C5 hemilaminectomy with hematoma removal (). On hematoma evacuation, there was no bleeding or oozing. Two weeks later, he was referred to the rehabilitation unit. At that time, motor examination of the left upper extremity, using the Medical Research Council (MRC) scale, revealed 0/5 elbow flexors, 1/5 wrist extensors, 2/5 elbow extensors, 2/5 finger flexors, and 0/5 finger abductors. Motor examination of the left lower extremity showed 1/5 hip flexors, 4/5 knee extensors, 1/5 ankle dorsiflexors, 1/5 long toe extensors, and 2/5 ankle plantarflexors. On sensory examination, there was diminished sensation to pinpricks below C6 on the right. Clean intermittent catheterization was educated and performed as he could not urinate voluntarily. The spinal cord independence measure (SCIM) was 25/100. He received rehabilitative management including neurophysiologic exercise therapy, functional occupational therapy, activities of daily living (ADL) training and functional electrical stimulation, consisting of 1 hour per session, 2 sessions a day, 5 days a week, for 4 months. At 5 months after the onset of symptoms, the left elbow flexors and finger abductors were 3/5. All other upper and lower extremities muscle groups were 4/5. Sensory examination showed decreased sensation to pinpricks below C7 on the right. He was able to ambulate with monocane and void voluntarily. SCIM improved to 80/100.