Spontaneous “zebras” have their day and should remain in

Spontaneous spinal epidural hematoma (SSEH) is a rare neurological condition. It can cause paraplegia, quadriplegia and even death, occur usually after the fourth or fifth decade 1. The male to female incidence ratio is 1.4:1 2. Cervicothoracic region or thoracolumbar region is the most commonly involved sites of a spontaneous spinal epidural hematoma with 40% of all cases have idiopathic etiology123. We are presenting a novel case of mid-50’s women who presented with a mid-thoracic lesion causing weakness and paralysis of the lower limbs. A spontaneous spinal epidural hematoma usually presents as severe back or neck pain that deteriorates rapidly toward paresis depending upon the location of the lesion. It can also cause spinal shock, urinary or stool incontinence with sensory and motor deficit 4. There are certain precipitating factors, including anticoagulation, thrombolytics, aspirin use, and vascular abnormalities appear to be correlated with spontaneous spinal epidural hematomas 56. A cough which is a trivial symptom and hundreds of people suffer on daily basis has never been associated as one of the potential risk factors for SSEH. This case is unique in a sense that our patient who presented with an intractable cough ended up as an SSEH which makes a cough as a potential etiology for SSEH.”Coughing has been shown to result in large and abrupt cerebrospinal fluid (CSF) pressure fluctuations, which arise, by communication between the CSF and intrathoracic pressures, through the venous system” 78.The mechanism of a cough induced SSEHs to arise from the epidural venous plexus in the spinal epidural space because it lacks venous valves and undulating pressure from the thoracic and abdominal cavities can impact it directly 129.  MRI is a current diagnostic method for SSEH and early surgical intervention is the key treatment for spontaneous spinal epidural hematomas 10. Just Like time is a brain, here early treatment can reduce mortality and morbidity and prevent serious neurological deficits. Prompt diagnosis and emergent decompressive surgical management have been recommended to prevent serious consequences. In conclusion, a spontaneous spinal epidural hematoma can occur with a minor trauma such as an increase in intra-spinal pressure caused by an intractable cough, is a rare case entity, which can be treated as a neurosurgical emergency. We highlight this case as a reminder that etiological factors deemed “zebras” have their day and should remain in the differential diagnosis of spontaneous spinal epidural hematomas no matter how rare they are.

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