Initial recognition failure of spontaneous spinal epidural hematoma in emergency care: symptom pattern and first-department allocation in a two- center cohort

Background Spontaneous spinal epidural hematoma (SSEH) is a rare, time-sensitive neurological emergency that may initially resemble more common emergency conditions. We evaluated the frequency of initial recognition failure in SSEH and examined its association with presenting symptom pattern and first-department allocation. Methods We retrospectively reviewed 51 consecutive patients with SSEH treated at two Japanese neurosurgical centers between 1995 and 2024. Initial recognition failure was defined as failure to recognize SSEH at first medical contact, resulting in a non-SSEH-directed diagnostic workup or treatment. Symptom pattern, initial medical department, diagnostic intervals, clinical severity, and radiological variables were extracted from medical records. Factors associated with initial recognition failure were explored using univariable logistic regression. Results Initial recognition failure occurred in 19 patients (37.3%). Initial working diagnoses included cerebral infarction (n = 6), aortic dissection (n = 4), spinal tumor (n = 3), lumbar disc herniation (n = 1), Guillain-Barre syndrome (n = 1), hyperkalemia (n = 1), spinal cord infarction (n = 1), vertebral artery dissection (n = 1), and other lumbar pain disorders (n = 1). Compared with Brown-Sequard pattern, transverse myelopathy was associated with higher odds of initial recognition failure (odds ratio [OR], 7.20; 95% confidence interval [CI], 1.63–31.71). Compared with initial evaluation in a general/emergency department, initial evaluation in a neurological department was associated with lower odds of initial recognition failure (OR, 0.03; 95% CI, 0.005–0.18). Conclusions Initial recognition failure was common in SSEH and was associated with both symptom pattern and first-department allocation. These findings suggest that SSEH should be considered early in emergency patients with severe acute neck, back, or truncal pain accompanied by any neurological symptom, even when the presentation appears bilateral, systemic, cardiovascular, or stroke-like. Awareness of this diagnostic pitfall among frontline emergency and non-neurological providers may facilitate earlier spinal cord localization and timely spinal MRI.