Spinal hematoma has been described in autopsies since 1682 and as a clinical 
diagnosis since 1867. It is a rare and usually severe neurological disorder 
that, without adequate treatment, often leads to death or permanent neurological 
deficit. Epidural as well as subdural and subarachnoid hematomas have been 
investigated. Some cases of subarachnoid spinal hematoma may present with 
symptoms similar to those of cerebral hemorrhage. The literature offers no 
reliable estimates of the incidence of spinal hematoma, perhaps due to the 
rarity of this disorder. In the present work, 613 case studies published between 
1826 and 1996 have been evaluated, which represents the largest review on this 
topic to date. Most cases of spinal hematoma have a multifactorial etiology 
whose individual components are not all understood in detail. In up to a third 
of cases (29.7%) of spinal hematoma, no etiological factor can be identified as 
the cause of the bleeding. Following idiopathic spinal hematoma, cases related 
to anticoagulant therapy and vascular malformations represent the second and 
third most common categories. Spinal and epidural anesthetic procedures in 
combination with anticoagulant therapy represent the fifth most common 
etiological group and spinal and epidural anesthetic procedures alone represent 
the tenth most common cause of spinal hematoma. Anticoagulant therapy alone 
probably does not trigger spinal hemorrhage. It is likely that there must 
additionally be a "locus minoris resistentiae" together with increased pressure 
in the interior vertebral venous plexus in order to cause spinal hemorrhage. The 
latter two factors are thought to be sufficient to cause spontaneous spinal 
hematoma. Physicians should require strict indications for the use of spinal 
anesthetic procedures in patients receiving anticoagulant therapy, even if the 
incidence of spinal hematoma following this combination is low. If spinal 
anesthetic procedures are performed before, during, or after anticoagulant 
treatment, close monitoring of the neurological status of the patient is 
warranted. Time limits regarding the use of anticoagulant therapy before or 
after spinal anesthetic procedures have been proposed and are thought to be safe 
for patients. Investigation of the coagulation status alone does not necessarily 
provide an accurate estimate of the risk of hemorrhage. The most important 
measure for recognizing patients at high risk is a thorough clinical history. 
Most spinal hematomas are localized dorsally to the spinal cord at the level of 
the cervicothoracic and thoracolumbar regions. Subarachnoid hematomas can extend 
along the entire length of the subarachnoid space. Epidural and subdural spinal 
hematoma present with intense, knife-like pain at the location of the hemorrhage 
("coup de poignard") that may be followed in some cases by a pain-free interval 
of minutes to days, after which there is progressive paralysis below the 
affected spinal level. Subarachnoid hematoma can be associated with meningitis 
symptoms, disturbances of consciousness, and epileptic seizures and is often 
misdiagnosed as cerebral hemorrhage based on these symptoms. Most patients are 
between 55 and 70 years old. Of all patients with spinal hemorrhage, 63.9% are 
men. The examination of first choice is magnetic resonance imaging. The 
treatment of choice is surgical decompression. Of the patients investigated in 
the present work, 39.6% experienced complete recovery. The less severe the 
preoperative symptoms are and the more quickly surgical decompression can be 
performed, the better are the chances for complete recovery. It is therefore 
essential to recognize the relatively typical clinical presentation of spinal 
hematoma in a timely manner to allow correct diagnostic and therapeutic measures 
to be taken to maximize the patient's chance of complete recovery.