Spinal Subdural Hematomas: Individual Patient Pooled Analysis on Presentation, Management and Outcomes

Introduction: Spinal subdural hematomas (SSDHs), though rare, can result from traumatic or spontaneous causes, presenting unique challenges across treatment options (surgical decompression, drainage, or conservative management). Despite the importance of prompt and tailored interventions, guidelines remain unclear on the timing and choice of treatment.

Methods: A systematic search was performed in pubmed, scopus, embase and web of science for studies about SSDHs in real world data. Data points included etiology, hematoma location, neurologic status, treatment type (early surgery < 24 hours, late surgery, drainage, or conservative), and outcomes (functional recovery, mortality). regression models were used to assess the impact of treatment choice on neurologic recovery, adjusting for age, sex, and hematoma location. Cox proportional hazards models evaluated time-to-outcome differences between early and late interventions.

Results: Among the 661 cases included from 361 case reports and case series, 68% were spontaneous, frequently associated with anticoagulant use (34%) and coagulopathy (48%). The thoracic spine was most affected (66%), and 78% of patients presented with neurological deficits. Early surgical decompression significantly improved neurological outcomes, with Kaplan-Meier survival analysis showing a 72% probability of favorable recovery in early surgery cases versus 41% in late surgery cases at six months (log-rank p < 0.001). The Cox proportional hazards model indicated a nearly two-fold higher likelihood of achieving neurological recovery with early surgery compared to late surgery (HR = 1.92, CI 1.56–2.36, p < 0.001). In contrast, conservative treatment was effective in 80% of asymptomatic or minimally symptomatic patients, while drainage was beneficial in 92% of selected cases, though it carried a higher recurrence risk in larger hematomas (>5 segments). Overall mortality was 1.3%, and permanent deficits occurred in 27%, stressing the impact of treatment timing.

Conclusion : This meta-analysis demonstrates that early surgical intervention within 24 hours significantly enhances recovery for symptomatic SSDH patients, whereas conservative management is appropriate for asymptomatic or minimally symptomatic cases. These findings underscore the importance of individualized, time-sensitive treatment decisions to optimize outcomes in SSDH.