Skip to main content

Advertisement

SpringerLink
Log in

SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review

  • Review
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

The neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, including spontaneous spinal hemorrhage (SSH), are diverse. SSH is a detrimental neurosurgical event requiring immediate medical attention. We aimed to investigate the association between SARS-CoV-2 and SSH and delineate a rational clinical approach. The authors searched PubMed, Scopus, Web of Science, and Google Scholar for studies published up to January 25, 2023, on SSH and SARS-CoV-2 infection. For each dataset, the authors performed pooled estimates examining three outcomes of interest: (1) early post-intervention neurological status, (2) mortality, and (3) post-intervention neurological rehabilitation outcomes. After reviewing 1341 results, seven datasets were identified for the final analysis. Fifty-seven percent of patients were females. Twenty-eight percent of the patients experienced severe systemic infection. The mean interval between the SARS-CoV-2 infection and neurological presentation was 18 days. Pain and sensorimotor deficits were the most common (57%). Spinal epidural hematoma (EDH) was the most common presentation (71.4%). Three patients were treated conservatively, while 4 received neurosurgical intervention. Pain and sensorimotor deficits had the best treatment response (100%), while the sphincter had the worst response (0%). Long-term follow-up showed that 71% of patients had good recovery. SARS-CoV-2-associated SSH is a rare complication of infection, with an often insidious presentation that requires high clinical suspicion. Patients with SARS-CoV-2 infection and new neurological symptoms or disproportionate neck or back pain require a neuroaxis evaluation. Neurosurgical intervention and conservative management are both viable options to treat SSH following COVID-19. Still, a homogenous approach to the treatment paradigm of SSH cannot be obtained, but lesions with space-occupying effects are suitable for neurosurgical evacuation-decompression while more indolent lesions could be treated conservatively. These options should be tailored individually until larger studies provide a consensus.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS et al (2020) Extrapulmonary manifestations of COVID-19. Nat Med 26(7):1017–1032. https://doi.org/10.1038/s41591-020-0968-3

    Article  PubMed  CAS  Google Scholar 

  2. Abobaker A, Raba AA, Alzwi A (2020) Extrapulmonary and atypical clinical presentations of COVID-19. J Med Virol 92(11):2458–2464. https://doi.org/10.1002/jmv.26157

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  3. Deeb A, Kumar PC, Sakrani N, Trehan RK, Papinenei VR (2021) Neurological presentations of COVID-19: characteristic features in a case series of hospitalized patients from Abu Dhabi UAE. Biomed Res Int 2021:5822259. https://doi.org/10.1155/2021/5822259

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  4. Figueroa J, DeVine JG (2017) Spontaneous spinal epidural hematoma: literature review. J Spine Surg 3(1):58–63. https://doi.org/10.21037/jss.2017.02.04

    Article  PubMed  PubMed Central  Google Scholar 

  5. Raasck K, Habis AA, Aoude A, Simões L, Barros F, Reindl R et al (2017) Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases 3:16043. https://doi.org/10.1038/scsandc.2016.43

    Article  PubMed  PubMed Central  Google Scholar 

  6. Zübeyde Ö, Adem K, Samet D (2022) A case of spontaneous thoracolumbar epidural hematoma in Covid-19 pneumonia. Int J Surg Case Rep 90:106719. https://doi.org/10.1016/j.ijscr.2021.106719

    Article  PubMed  Google Scholar 

  7. Lim SW, Wong E (2020) Spontaneous epidural hematoma of the cervical spine in an elderly woman with recent COVID-19 infection: a case report. Am J Case Rep 21:e926784. https://doi.org/10.12659/ajcr.926784

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sabouri M, Rezvani M, Aminmansour B, Sourani A, Baradaran MS (2022) Spontaneous intramedullary hematoma in a patient with COVID-19 infection: a case report. Clin Case Rep 10(2):e05387. https://doi.org/10.1002/ccr3.5387

    Article  PubMed  PubMed Central  Google Scholar 

  9. Romagna A, Potthast F, Steinborn MM, Burdach S, Lehmberg J (2022) Surgical treatment of a spontaneous spinal epidural hematoma under antithrombotic treatment of a multisystem inflammatory syndrome in children associated with SARS-COV-2. Childs Nerv Syst 38(6):1213–1216. https://doi.org/10.1007/s00381-021-05375-6

    Article  PubMed  Google Scholar 

  10. Scalia G, Umana GE, Marrone S, Graziano F, Giuffrida A, Ponzo G et al (2021) Spontaneous anterior cervicothoracic spinal epidural hematoma extending to clivus in SARS-CoV-2 infection. Surg Neurol Int 12:181. https://doi.org/10.25259/sni_40_2021

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dlaka D, Vavro H, Romić D, Almahariq F, Chudy D, Lukšić I et al (2022) Spontaneous spinal subdural hematoma in COVID-19 patient: Croatian national COVID hospital experience. Surg Neurol Int 13:394. https://doi.org/10.25259/sni_87_2022

    Article  PubMed  PubMed Central  Google Scholar 

  12. Chu EC, Trager RJ, Lai CR, Shum JS (2022) Spontaneous cervical epidural hematoma following COVID-19 illness presenting to a chiropractor: a case report. Cureus 14(12):e32199. https://doi.org/10.7759/cureus.32199

    Article  PubMed  PubMed Central  Google Scholar 

  13. Garg RK, Paliwal VK, Gupta A (2021) Spinal cord involvement in COVID-19: a review. J Spinal Cord Med:1–15. https://doi.org/10.1080/10790268.2021.1888022

  14. Mondal R, Deb S, Shome G, Ganguly U, Lahiri D, Benito-León J (2021) COVID-19 and emerging spinal cord complications: a systematic review. Mult Scler Relat Disord 51:102917. https://doi.org/10.1016/j.msard.2021.102917

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  15. Jafari Khaljiri H, Jamalkhah M, Amini Harandi A, Pakdaman H, Moradi M, Mowla A (2021) Comprehensive review on neuro-COVID-19 pathophysiology and clinical consequences. Neurotox Res 39(5):1613–1629. https://doi.org/10.1007/s12640-021-00389-z

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Margos NP, Meintanopoulos AS, Filioglou D, Ellul J (2021) Intracerebral hemorrhage in COVID-19: a narrative review. J Clin Neurosci 89:271–278. https://doi.org/10.1016/j.jocn.2021.05.019

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  17. Fraiman P, Freire M, Moreira-Neto M, Godeiro-Junior C (2020) Hemorrhagic stroke and COVID-19 infection: coincidence or causality? eNeurologicalSci 21:100274. https://doi.org/10.1016/j.ensci.2020.100274

    Article  PubMed  PubMed Central  Google Scholar 

  18. Chian Chiang Nicholas C, John M, Jerome I, Yuen S (2020) Acute transverse myelitis in COVID-19 infection. BMJ Case Rep 13(8):e236720. https://doi.org/10.1136/bcr-2020-236720

    Article  Google Scholar 

  19. Gulati N, Kapila S, Bhalla Sehgal L, Sehgal V, Lnu P (2022) Myelitis following COVID-19 illness. Cureus 14(8):e28134. https://doi.org/10.7759/cureus.28134

    Article  PubMed  PubMed Central  Google Scholar 

  20. Beyrouti R, Best JG, Chandratheva A, Perry RJ, Werring DJ (2021) Characteristics of intracerebral haemorrhage associated with COVID-19: a systematic review and pooled analysis of individual patient and aggregate data. J Neurol 268(9):3105–3115. https://doi.org/10.1007/s00415-021-10425-9

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  21. Leasure AC, Khan YM, Iyer R, Elkind MSV, Sansing LH, Falcone GJ et al (2021) Intracerebral hemorrhage in patients with COVID-19: an analysis from the COVID-19 Cardiovascular Disease Registry. Stroke 52(7):e321–e3e3. https://doi.org/10.1161/strokeaha.121.034215

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  22. Kaushik RM, Kumar R, Kaushik M, Saini M, Kaushik R (2022) Spontaneous spinal intradural hemorrhage in dengue fever: a case report. J Med Case Rep 16(1):213. https://doi.org/10.1186/s13256-022-03451-2

    Article  PubMed  PubMed Central  Google Scholar 

  23. Patel H, Boaz JC, Phillips JP, Garg BP (1998) Spontaneous spinal epidural hematoma in children. Pediatr Neurol 19(4):302–307. https://doi.org/10.1016/s0887-8994(98)00059-9

    Article  PubMed  CAS  Google Scholar 

  24. Leep Hunderfund AN, Wijdicks EF (2009) Intramedullary spinal cord hemorrhage (hematomyelia). Rev Neurol Dis 6(2):E54–E61

    PubMed  Google Scholar 

  25. Peng D, Yan M, Liu T, Yang K, Ma Y, Hu X et al (2022) Prognostic factors and treatments efficacy in spontaneous spinal epidural hematoma: a multicenter retrospective study. Neurology 99(8):e843–ee50. https://doi.org/10.1212/wnl.0000000000200844

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  26. Bakker NA, Veeger NJ, Vergeer RA, Groen RJ (2015) Prognosis after spinal cord and cauda compression in spontaneous spinal epidural hematomas. Neurology 84(18):1894–1903. https://doi.org/10.1212/wnl.0000000000001545

    Article  PubMed  Google Scholar 

  27. Sheng OC, Wu R-C, Chang IH (2021) Spontaneous spinal epidural hematoma: a case report. Int J Emerg Med 14(1):60. https://doi.org/10.1186/s12245-021-00379-0

    Article  PubMed  PubMed Central  Google Scholar 

  28. Sourani A, Rezvani M, Foroughi M, Baradaran MS (2022) Spontaneous intramedullary hematoma following COVID-19 vaccination: a case report. Clin Case Rep 10(12):e6743. https://doi.org/10.1002/ccr3.6743

    Article  PubMed  PubMed Central  Google Scholar 

  29. Maghrabi Y, Baeesa SS (2021) Acute hemorrhagic myelitis in an adolescent with COVID-19: a case report and review of literature. Cureus 13(12):e20553. https://doi.org/10.7759/cureus.20553

    Article  PubMed  PubMed Central  Google Scholar 

  30. Schulte EC, Hauer L, Kunz AB, Sellner J (2021) Systematic review of cases of acute myelitis in individuals with COVID-19. Eur J Neurol 28(10):3230–3244. https://doi.org/10.1111/ene.14952

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to thank the departments of Neurosurgery and Physical Medicine and Rehabilitation of Isfahan University of Medical Sciences, Isfahan, Iran. In addition, this work could not be completed without receiving valuable comments from the Department of Radiology, University of California, San Diego Health, San Diego, California, USA.

Author information

Author notes

  1. Arman Sourani and Sadegh Baradaran Mahdavi equally contributed as corresponding authors.

Authors and Affiliations

  1. Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran

    Arman Sourani & Majid Rezvani

  2. Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran

    Arman Sourani

  3. Department of Radiology University of California, San Diego Health, San Diego, CA, USA

    Noushin Vahdat & Ryan Mirza

  4. Department of Radiology Veteran Administration Healthcare System, San Diego, CA, USA

    Noushin Vahdat

  5. Neurosurgical Associates of San Antonio, San Antonio, TX, USA

    Colin Son

  6. School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX, USA

    Colin Son

  7. Department of Neurological Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA

    Omid R. Hariri

  8. Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran

    Mina Foroughi & Armin Sourani

  9. Department of Physical Medicine and Rehabilitation, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

    Sadegh Baradaran Mahdavi

  10. Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran

    Sadegh Baradaran Mahdavi

Authors
  1. Arman Sourani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Noushin Vahdat
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Colin Son
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Omid R. Hariri
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Majid Rezvani
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mina Foroughi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ryan Mirza
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Armin Sourani
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sadegh Baradaran Mahdavi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Arman S contributed to the conception of the work, data search, data extraction, manuscript preparation, manuscript revision, final approval of the manuscript and agreed to be accountable for all aspects of the work.

NV contributed to manuscript preparation, data verification, English language processing, final approval of the manuscript and agreed to be accountable for all aspects of the work.

CS contributed to manuscript preparation, scientific review, English language processing, final approval of the manuscript and agreed to be accountable for all aspects of the work.

OH contributed to manuscript preparation, scientific review, English language processing, final approval of the manuscript and agreed to be accountable for all aspects of the work.

MR contributed to data gathering, scientific review, final approval of the manuscript and agreed to be accountable for all aspects of the work.

MF contributed to manuscript preparation, final approval of the manuscript and agreed to be accountable for all aspects of the work.

RM contributed to manuscript revision and English language editing, final approval of the manuscript and agreed to be accountable for all aspects of the work.

Armin. S contributed to data verification, article review, final approval of the manuscript and agreed to be accountable for all aspects of the work.

SBM contributed to the conception of the work, data search, data extraction, manuscript preparation, manuscript revision, final approval of the manuscript and agreed to be accountable for all aspects of the work.

Corresponding authors

Correspondence to Arman Sourani or Sadegh Baradaran Mahdavi.

Ethics declarations

Competing interest

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendices

Appendix 1. Search strings

Search string for PubMed

((“Spinal Hematoma”[Title/Abstract] OR “Subdural Hematoma*”[Title/Abstract] OR “Subdural Hemorrhage*”[Title/Abstract] OR SDH[Title/Abstract] OR “Subarachnoid Hemorrhage*”[Title/Abstract] OR SAH[Title/Abstract] OR “Epidural Hemorrhage*”[Title/Abstract] OR “Extradural Hematoma*”[Title/Abstract] OR EDH[Title/Abstract] OR Hematomyelia[Title/Abstract] OR “Spinal Cord Hemorrhage*”[Title/Abstract]) OR (“Hematoma, Subdural”[Mesh] OR “Subarachnoid Hemorrhage” [Mesh] OR “Hematoma, Epidural, Spinal” [Mesh] OR “Spinal Cord Vascular Diseases” [Mesh])) AND ((COVID-19[Title/Abstract] OR SARS-CoV-2[Title/Abstract] OR 2019-nCoV[Title/Abstract] OR “Coronavirus Disease 19”[Title/Abstract] OR “2019 Novel Coronavirus”[Title/Abstract]) OR (COVID-19 [Mesh] OR SARS-CoV-2 [Mesh]))

167 Records [with these filters: Full text, Humans, English]

Search string for Web of Science

“Spinal Hematoma” OR “Subdural Hematoma*” OR “Subdural Hemorrhage*” OR SDH OR “Subarachnoid Hemorrhage*” OR SAH OR “Epidural Hemorrhage*” OR “Extradural Hematoma*” OR EDH OR Hematomyelia OR “Spinal Cord Hemorrhage*” (All Fields) and COVID-19 OR SARS-CoV-2 OR 2019-nCoV OR “Coronavirus Disease 19” OR “2019 Novel Coronavirus” (All Fields)

316 Records [with these filters: Article, English]

Search string for Scopus

( TITLE-ABS-KEY ( “Spinal Hematoma” OR “Subdural Hematoma*” OR “Subdural Hemorrhage*” OR sdh OR “Subarachnoid Hemorrhage*” OR sah OR “Epidural Hemorrhage*” OR “Extradural Hematoma*” OR edh OR hematomyelia OR “Spinal Cord Hemorrhage*” ) AND TITLE-ABS-KEY ( covid-19 OR sars-cov-2 OR 2019-ncov OR “Coronavirus Disease 19” OR “2019 Novel Coronavirus” ) ) AND ( LIMIT-TO ( DOCTYPE , “ar” ) ) AND ( LIMIT-TO ( LANGUAGE , “English” ) ) AND ( LIMIT-TO ( SRCTYPE , “j” ) )

389 Records [with these filters: Journal, Article, English]

Search string for Embase

(‘spinal hematoma’/exp OR ‘spinal hematoma’ OR ‘subdural hematoma*’ OR ‘subdural hemorrhage*’ OR ‘sdh’/exp OR sdh OR ‘subarachnoid hemorrhage*’ OR sah OR ‘epidural hemorrhage*’ OR ‘extradural hematoma*’ OR ‘edh’/exp OR edh OR ‘hematomyelia’/exp OR hematomyelia OR ‘spinal cord hemorrhage*’) AND (‘covid 19’/exp OR ‘covid 19’ OR ‘sars cov 2’/exp OR ‘sars cov 2’ OR ‘2019 ncov’/exp OR ‘2019 ncov’ OR ‘coronavirus disease 19’/exp OR ‘coronavirus disease 19’ OR ‘2019 novel coronavirus’/exp OR ‘2019 novel coronavirus’)

469 Records [with this filter: Article]

Appendix 2

Table 4 Methodological quality assessment of included studies1
Full size table

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sourani, A., Vahdat, N., Son, C. et al. SARS-CoV-2 infection and spontaneous spinal hemorrhage: a systematic review. Neurosurg Rev 46, 300 (2023). https://doi.org/10.1007/s10143-023-02211-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10143-023-02211-0

Keywords

Search

Navigation