Working Diagnosis:
Spontaneous Spinal Epidural Hematoma (SSEH) at L4-5 and L5-S1

Treatment:
The patient was managed conservatively given minimal and stable clinical findings. Neurosurgery referral did not alter management, as they anticipated patient's symptoms would improve as his hematoma was reabsorbed. A review of the literature could not identify a standard of care for return to activity following SSEH. Nevertheless, the patient was given a personalized return to activity schedule, focusing on cardiovascular and aerobic exercise, while restricting him from exercise that could induce valsalva. Particularly, this meant avoiding any activity that involved straining while holding his breath, such as weight lifting, performing sit-ups, swimming and playing wind-instruments.

Outcome:
Serial follow-up appointments, at weeks 7 and 10, showed slow but gradual improvement in pain and strength. Repeat MRI Case Photo #5 , Case Photo #6 at week 8 showed "decreased size of proteinaceous cystic epidural collection posterior to L5 vertebral body" with improved compression of both thecal sac and right L5 nerve root. By week 14 patient's pain has resolved and his strength was back to baseline. He did not follow up with physical therapy.

Author's Comments:
The etiology of SSEH is thought to be high pressure within the vertebral venous plexus induced by valsalva. It is an extremely rare occurrence, with an incidence of only 0.1 in 100,000. This patient's presentation was particularly uncommon: he was 24 years old (the median age of SSEH is 52), he had radiating pain at onset (89% have only localized neck/back pain), his hematoma was located at L4-S1 (less than 9% of SSEH are located below the L2 level), and he was managed conservatively (92% require emergent decompression).

Editor's Comments:
This case illustrates a rare zebra in the differential of lumbar disc herniation. MRI altered management such that activities that induce valsalva were to be avoided. In cases of rapidly developing neurologic sequelae, surgical intervention is warranted.

References:
1. Bakker, Nicolaas A., et al. "Prognosis after spinal cord and cauda compression in spontaneous spinal epidural hematomas." Neurology 84.18 (2015): 1894-1903.
2. Bose, S., et al. "Spontaneous spinal epidural haematoma: a rare cause of quadriplegia in the post-partum period." British journal of anaesthesia 99.6 (2007): 855-857.
3. Chen, Chun-Lin, Ching-Hsiang Lu, and Nan-Fu Chen. "Spontaneous spinal epidural hematoma presenting with quadriplegia after sit-ups exercise." The American journal of emergency medicine 27.9 (2009): 1170-e3.
4. Chen, Chi-Jen, et al. "Spontaneous spinal epidural haematomas with repeated remission and relapse." Neuroradiology 39.10 (1997): 737-740.
5. David, Scott, et al. "Spontaneous cervicothoracic epidural hematoma following prolonged Valsalva secondary to trumpet playing." The American journal of emergency medicine 15.1 (1997): 73-75.
6. Fleager, Kristen, et al. "Massive Spontaneous Epidural Hematoma in a High-Level Swimmer." JBJS Case Connector 17 (2010): 2843-2846.
7. Groen, Rob JM, and Piet VJM Hoogland. "High blood pressure and the spontaneous spinal epidural hematoma: the misconception about their correlation." European Journal of Emergency Medicine 15.2 (2008): 119-120.
8. Groothuis, J. T. "Postpartum spinal cord injury in a woman with HELLP Syndrome.(vol 31, pg 309, 2008)." JOURNAL OF SPINAL CORD MEDICINE31.5 (2008): 499-499.
9. Kreppel, D., G. Antoniadis, and W. Seeling. "Spinal hematoma: a literature survey with meta-analysis of 613 patients." Neurosurgical review 26.1 (2003): 1-49.
10. Kingery, Wade S., et al. "The natural resolution of a lumbar spontaneous epidural hematoma and associated radiculopathy." Spine 19.1 (1994): 67-69.
11. Silber, Steven H. "Complete nonsurgical resolution of a spontaneous spinal epidural hematoma." The American journal of emergency medicine 14.4 (1996): 391-393.
12. Uber-Zak, Lori D., and Y. Swamy Venkatesh. "Neurologic complications of sit-ups associated with the Valsalva maneuver: 2 case reports." Archives of physical medicine and rehabilitation 83.2 (2002): 278-282.
13. Vitali, Aleksander M., and Paul Steinbok. "Spontaneous spinal epidural hematoma following weight lifting." The Canadian Journal of Neurological Sciences 35.02 (2008): 262-264.

Acknowledgments:
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