Remote thoracic spinal subdural hematoma after lumbar fusion: a case report

Remote thoracic spinal subdural hematoma after lumbar surgery is exceptionally rare and may be overlooked when postoperative neurological deterioration is initially attributed to the operated lumbar level. A 64-year-old woman with Grade 3 hypertension, scoliosis, and a body mass index of 24.66 kg/m² underwent conventional open posterior midline L5–S1 transforaminal lumbar interbody fusion. No dural tear or cerebrospinal-fluid leakage was documented, and estimated blood loss was 100 mL. She received enoxaparin 40 mg subcutaneously on postoperative days 1 and 2. At 00:25 on postoperative day 3, she developed new thoracic back pain, followed at 02:15 by abrupt paraplegia and sensory loss, approximately 59 hours 40 minutes after the lumbar operation ended. Urgent magnetic resonance imaging showed a posterior T7–T9 intradural hematoma with an inverted Mercedes-Benz configuration. At maximal compression, hematoma thickness was 5.81 mm within a same-axis canal diameter of 11.03 mm, corresponding to a 52.7% linear diameter ratio. Emergency posterior decompression and durotomy revealed a predominantly subdural clot and a smaller fragment adjacent to the arachnoid. A 0.8 × 0.8 cm proximal dural window was retained to provide decompression if residual or recurrent subdural blood accumulated. Histopathology showed inflammatory exudate, fibrinoid necrotic material, and extensive hemorrhage without neoplasm. Motor and sphincter function improved by 3 months. At 1 year, the patient could walk approximately 10 m with a walker but continued to report lower-extremity motor and sensory impairment, residual bowel and bladder dysfunction, and perianal numbness. Remote thoracic spinal subdural hematoma should be considered when severe neurological deficits after lumbar surgery are not explained by the operated level. New thoracic pain followed by rapid neurological decline should prompt urgent imaging beyond the lumbar region. In this case, quantitative MRI, operative confirmation, and the response to decompression demonstrated clinically important focal thoracic cord compression. The perioperative pattern supports a multifactorial hemodynamic association involving blood-pressure variability, hypertension, anticoagulant exposure, and possible CSF–venous interactions. The proximal dural window was used as an individualized decompressive adjunct, with no clinically recognized related complication during 1-year follow-up. Not applicable.