Spinal epidural hematoma (SEH) is a rare disease that causes acute spinal cord compression. SEH is caused by an idiopathic, spontaneous, arteriovenous malformation, trauma, lumbar puncture, or anticoagulant medication. Traumatic SEH accounts for 0.5–1.7% of all spinal injuries and at least 40% of all spontaneous SEH [1,2]. Specifically, epidural steroid injections are widely used for neck and pain or radiculopathy; however, various side effects have been reported. Transforaminal cervical and lumbar epidural steroid injections pose a potential risk of fatal vascular injury [3]. The clinical symptoms mainly include acute pain, paralysis, quadriplegia, paresthesia, sexual dysfunction, and intestinal and/or bladder dysfunction. These entail a high risk of neurological sequelae; therefore, early diagnosis and rapid treatment are needed. Magnetic resonance imaging (MRI) or computed tomography (CT) aid in its diagnosis. The treatment involves embolization or surgical evacuation of hematomas [4-6].

In traditional Korean medicine (TKM), vascular diseases of the spinal cord are categorized as “wilting disorders.” It is characterized by general weakness of the muscles of the extremities and limitation of free movements [4-7]. To our knowledge, no studies have addressed TKM treatments for spinal hematoma following epidural injections. In Korea, few studies have reported spontaneous epidural bleeding or subsequent anticoagulant ingestion [4,5]. Thus, this case report aimed to describe the effectiveness of TKM treatment in patients with SEH.

1. Patient

Lee OO (female, 82 years old).

The chief complaint included low back pain, buttock pain, bilateral lower limb paresthesia, gait disturbance.

The patient had an old burst fracture of T12 and L1 bodies with vertebroplasty in 2021. She was diagnosed with rheumatoid arthritis, diabetes, and hyperlipidemia and was taking her prescribed medications.

None.

The patient received epidural steroid injections three times for back pain at local hospital on January 27, and February 3 and 10, 2022. After the third injection, the patient noted unprecedented back pain, numbness, and paresthesia in both legs and inability to walk. On February 10–17, 2022, she was hospitalized at the local neurosurgery hospital, and from February 17 to March 4, 2022, she was hospitalized at the neurosurgery department of Soonchunhyang University Hospital, but surgery was not performed.

The patient was hospitalized for 22 days from March 4–25, 2022.

MR images of the thoracolumbar spine were obtained on February 17 and 22, 2022 (Figs. 1, 2).

Figure 1. T2-weighted magnetic resonance images of thoracolumbar spine showing an acute spinal epidural hematoma (SEH) performed on February 17, 2022. The image on the left (A) is the sagittal view with spinal cord compression at the T8–L4 level (green arrows). The image on the right side (B, C) is the axial view of the SEH. The image on the right upper side (B) is at the T9–10 level, and the right lower side (C) is at the T12–L1 level. The scan shows distended epidural space with low signal (green arrow).

Figure 2. T2-weighted magnetic resonance images of thoracolumbar spine showing an acute spinal epidural hematoma (SEH) performed on February 22, 2022. The (A) is the sagittal view with spinal cord compression at the T8–L4 level (green arrows). The (B, C) are the axial view of the SEH. The B image is at the T9–10 level, and the (C) is at the T12–L1 level. The scan shows distended epidural space with low signal (green arrow).

To protect the patient’s personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (No. DJUMC-2022-BM-09).

2. Treatments methods

The acupuncture needles used were 0.25 × 30-mm stainless steel standardized and disposable needles (Eastern Acupuncture Equipment Manufacture, Boryeong, Korea). Acupuncture was performed twice daily for 15 minutes: bilateral BL23, BL24, BL25, and BL26; unilateral ST36, ST37, ST40, BL60, GB30, and GB34; and tender points on tissues, including the gluteus and piriformis muscles [8]. STN-110 (Stratek, Seoul, Korea), set with a stimulation frequency of 3 Hz, was used for electroacupuncture [9,10].

Pharmacopuncture was administered once daily from March 5 to 10, 2022. Aconitum ciliare decaisne pharmacopuncture (ACDP) (Korean Pharmacopuncture Institute, Seoul, Korea) was injected at BL23, BL24, BL25, or tender points around the hip. A dose of 0.1–0.2 mL was injected at each acupoint at a depth of 1–1.2 cm. The total dose administered per treatment was 1.0 mL, using a 1.0-mL disposable syringe with needle (30 G × 1.27-cm needle; Jungrim Medical, Seoul, Korea).

The patient received herbal medicines three times daily. Whallak-tang, Sungihwalhyeol-tang, Gamiojeoksan, and Gwiwon-tang were prescribed (Table 1).

Table 1 . Herbal composition of four herbal medications for daily dosage.

Whallak-tang (2022.03.05–2022.03.07)	(g)	Sungihwalhyeol-tang (2022.03.09–2022.03.11)	(g)	Gamiojeoksan (2022.03.12–2022.03.14)	(g)	Gwiwon-tang (2022.03.15–2022.03.21)	(g)
Chaenomelis fructus	20	Cyperi rhizoma	16	Atractylodis rhizoma	16	Longan arillus	16
Chelidonii herba	20	Linderae radix	8	Clematidis radix	12	Rehmanniae radix preparata	16
Corydalis tuber	16	Citri unshius pericarpium	8	Pinelliae tuber	4	Astragali radix	16
Osterici radix	16	Pinelliae tuber	8	Citri unshius pericarpium	8	Atractylodis rhizoma alba	16
Clematidis radix	12	Poria sclerotium	8	Poria sclerotium	8	Poria sclerotium	16
Angelicae pubescentis radix	12	Atractylodis rhizoma	8	Angelicae gigantis radix	8	Liriopis seu ophiopogonis tuber	16
Angelicae gigantis radix	12	Cnidii rhizoma	18	Paeoniae radix alba	8	Angelicae gigantis radix	8
Rehmanniae radix siccus	12	Paeoniae radix rubra	8	Cnidii rhizoma	8	Cyperi rhizoma	8
Paeoniae radix rubra	12	Platycodonis radix	8	Ephedrae herba	4	Zizyphi spinosi semen	8
Atractylodis rhizoma	8	Aurantii fructus immaturus	8	Cinnamomi ramulus	8	Nelumbinis semen	8
Citri unshius pericarpium	8	Angelicae dahuricae radix	6	Aurantii fructus immaturus	6	Citri unshius pericarpium	8
Olibanum	8	Aucklandiae radix	6	Platycodonis radix	6	Amomi fructus	8
Myrrha	6	Glycyrrhizae radix	6	Zingiberis rhizoma	6	Polygoni multiflori radix alba	8
Carthami flos	6	Cinnamomi ramulus	6	Angelicae dahuricae radix	6	Ponciri fructus immaturus	6
Amomi fructus	4	Persicae semen	6	Zingiberis rhizoma recens	6	Pinelliae tuber	6
Glycyrrhizae radix	8	Carthami flos	6	Allii fistulosi bulbus	8	Aucklandiae radix	4
Crataegii fructus	8	Acori graminei rhizoma	4	Angelicae pubescentis radix	8	Chrysanthemi indici flos	4
Galli stomachichum corium	8	Polygalae radix	4	Achyranthis radix	8	Menthae herba	4
Massa medicata fermentata	8	Angelicae gigantis radix	10	Dipsaci radix	8	Phyllostachyos caulis in taeniam	4
Hordei fructus germiniatus	8	Zingiberis rhizoma recens	4	Osterici radix	8	Polygalae radix	4
						Coptidis rhizoma	4
						Glycyrrhizae radix	4
						Zingiberis rhizoma recens	24
						Zizyphi fructus	16
						Crataegii fructus	8
						Massa medicata fermentata	8
						Acanthopanacis cortex	8
						Achyranthis radix	8
						Chaenomelis fructus	8

To reduce pain and relieve muscle tension, transcutaneous electrical nerve stimulation was applied once daily for 20 minutes to the lower back region.

Indirect electric moxibustion therapy (Technoscience, Seoul, Korea) was applied twice a day for 10 minutes at BL24, BL25, BL26, ST36, and GB34.

Tilt training involves training in the standing posture by tilting the patient who cannot walk or stand independently. It was performed daily for 20 minutes four times a week from day 8 of hospitalization (March 11, 2022) for strengthening muscle in the lower extremities before practice walking [11].

3. Evaluation

A scale of 0–10 was used as an index to grade the subjective pain felt by the patient, where 0 and 10 indicated no pain and maximum pain, respectively (Fig. 3).

Figure 3. Changes in the Numeric Rating Scale score from March 4, 2022 to March 25, 2022.

The American Spinal Injury Association (ASIA) is a standardized examination tool that measures the sensation and muscle strength of both upper and lower limbs to neurologically and functionally classify spinal cord injuries [12,13]. The total score is 100 points, with 50 points each in the upper and lower extremities (Appendix A) (Fig. 4).

Figure 4. Changes in the ASIA and SCIMIII score. ASIA, American Spinal Injury Association scale; SCIMIII, Spinal Cord Independence Measure version III.

Spinal Cord Independence Measure version III (SCIMIII) is used to measure quadriplegia and lower extremity paralysis more sensitively in patients with spinal cord injury. It is divided into self-help skills, respiratory and sphincter control, and movements. The total score is 100 points, with a higher score indicating better performance [4,5,14] (Appendix B) (Fig. 4).

When the patient was stimulated with a needle, if the level of normal sensation is 10, the level of sensory abnormality in the vertebral segments below L4 was measured on a scale of 0–10 (Fig. 5).

Figure 5. Subjective evaluation of the patient during the hospitalization. The subjective senses of both lower extremities were evaluated by comparing them with other parts with normal sensations.

4. Patient’s progress during treatment

The patient’s pain, muscle strength, and subjective sensation improved during the inpatient treatment (Fig. 6). The Numerical Rating Scale (NRS) decreased from 7 to 2. The ASIA and SCIM III scores increased from 65 to 95 and from 32 to 69, respectively. The subjective sensory score increased from 1 to 8. On admission, the patient could not walk and had a Foley catheter inserted. At discharge, the patient could walk for approximately 10 minutes with assistance and could actively raise her legs up to 70°.

Figure 6. Timetable of patient history and clinical symptoms. SEH, spinal epidural hematoma; MRI, magnetic resonance imaging; ROM, range of motion; NRS, Numerical Rating Scale; ASIA, American Spinal Injury Association scale; SCIMIII, Spinal Cord Independence Measure version III.

SEH is caused by hemorrhagic conditions, trauma to the spine, and vascular malformation and is prevalent in the thoracic region where the epidural space is best developed. Traumatic injuries include spinal fractures, lumbar puncture, and postoperative bleeding. The site and degree of bleeding affect the patient’s condition and prognosis, and bleeding in the cervical and thoracic spine is more severe than that in the lumbar spine [5]. SEH can cause acute neurological and chronic lumbar spine symptoms. Pain, motor paralysis, and sphincter dysfunction may also occur [15]. Diagnoses are based on MRI or CT and indicate immediate surgical removal. MRI is the best diagnostic modality, visualizing several vertebral segments along the longitudinal axis. Delayed treatment can result in neurological damage and poor prognoses [4-6,15].

The results of this study indicated that TKM treatment, including acupuncture, moxibustion, and herbal medicine, can improve spinal hematoma as a side effect of epidural steroid injection. Moreover, TKM treatment focuses on the communication of meridians, promotion of blood circulation and nerve function recovery, and replenishment of qi and blood. Through this, the flow of qi and blood reaching the lower limbs is stagnant because of hematomas in the thoracolumbar region, and it treats symptoms such as pain, muscle weakness, and decreased sensation caused by a lack of nutrition in the skin and muscles.

In TKM, “wilting syndrome,” also called “Wei-syndrome,” a spinal vascular disease, causes muscle weakness and thinness of the limbs [4,5,7]. Herbal medicine treatment focused on communicating the meridians, stimulating blood circulation, and then replenishing qi and blood. In this study, Whallak-tang was prescribed to alleviate severe pain and promote meridian. To relieve the patient’s complaints of nausea and abdominal distension, Sungihwalhyeol-tang was prescribed and Gamiojeoksan was added to relieve dry cough, pain, and itching. Gwiwon-tang was prescribed to help the patient recover and regain her appetite (Table 1). Acupuncture, electroacupuncture, and ACDP were mainly applied for the treatment on the acupuncture point of the bladder meridian and stomach meridian, stimulating the dermal segment of the spine to recover senses and restore the contractility of the tibial muscle. Acupuncture promotes qi and blood circulation on Back-Shu points, which is the damaged area of the spinal cord, and restores the nerve through stimulation by selecting the acupoint at the location of the nerve in the paralyzed area [8]. Electroacupuncture increases the electrical activity of the muscles to treat paresthesia, and it is applied to the tibialis anterior and peroneus muscles of the lower extremities. ACDP helps reduce neuropathic pain [16], increase body temperature, improve peripheral blood circulation, and have anti-inflammatory effects [17].

Two studies have reported vascular diseases of the spinal cord treated by TKM. Lee et al. [4] reported two cases, and no surgery was performed. TKM was started 5–7 weeks after onset and was performed for 3–4 months. In this study, bee venom was injected into Back-Shu points to induce nerve cell activity and improve sensory impairment. In the first case, muscle strength was unchanged, and the sensory response of two segments was recovered. In the second case, partial sensation was recovered and muscle strength was restored, enabling independent walking instead of using a cane. By contrast, the patient recovered her sensation after 3 weeks of conservative treatment. This study showed that TKM was effective in that the patient who could not walk initially could walk with reduced pain and had increased muscle strength. Oh et al. [5] reported a case that occurred during anticoagulant therapy. TKM was performed 3 months after surgery, and improvements were observed after 4 months of treatment. The same treatment interventions were used, and pharmacoacupuncture was also employed in our patient. Both studies are comparable in that the herbal medicine prescription was changed several times to reduce pain, restore energy, and improve abdominal discomfort in patients who mainly lie down after hematoma. Although the comparison is limited because of the different acute/chronic durations, the treatment was effective in a relatively shorter time than the general prognosis.

Treatment was terminated early because the patient had to be discharged because of coronavirus disease 2019; however, compared with the hospitalization period, she showed sufficient improvement from 7 to 2 on the NRS, 65 to 95 points on the ASIA, and 32 to 69 points on the SCIMIII.

To our knowledge, this is the first case of traumatic epidural hematoma following spinal epidural injections, and TKM could be effective in improving nerve recovery, muscle strength, and sensation in patients with epidural hemorrhage based on improvements in NRS, ASIA, and SCIMIII indicators. However, this study has a limitation for reporting only one case; thus, studies on a larger number of patients are warranted to comprehensively examine the effects of acupuncture, electroacupuncture, and herbal medicine treatment. Since the patient started receiving TKM treatment at this hospital 3 weeks after the symptom onset, the disease may have progressive healing naturally. Nevertheless, this study is meaningful because cases treated using TKM, with improvement in subjective and objective symptoms, are rarely reported.

Conceptualization: YYC, HL. Methodology: YYC. Formal investigation: YYC. Data analysis: YYC. Writing – original draft: YYC. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This study was exempt from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No. DJUMC-2022-BM-09).