INTRODUCTION: Spinal epidural hematoma (SEH) is a rare disease that causes cord 
compression and neurologic deficit. Spontaneous SEH is related to minor trauma, 
bleeding disorders, and anticoagulant medications. Posttraumatic SEH has been 
associated with low-energy spine hyperextension injuries in patients with 
ankylosing spinal disorders such as ankylosing spondylitis and diffuse 
idiopathic skeletal hyperostosis (DISH). A variant named atypical DISH-like with 
SEH is reported.
OBJECTIVE: To describe the management, diagnosis, and treatment of an unusual 
SEH case in a patient causing delayed neurologic deficit with rigid atypical 
DISH-like spine.
CASE DESCRIPTION: An elderly woman with prior antiplatelet therapy presented 
with delayed neurological deficit suffering trauma after falling. Computed 
tomography (CT) imaging studies reveal hyperextension fracture pattern and signs 
mimic DISH missed on standard X-ray images. Magnetic resonance (MR) study 
demonstrates posterior epidural mass compatible with SEH in thoracic spine with 
cord compression. Using a midline posterior approach, an urgent intervention and 
a left multiple partial unilateral decompressive laminectomy at T4-T7 and a long 
instrumented fusion at T3-T9 were performed for achieving spinal stability and 
neurological improvement, both of which were observed.
CONCLUSION: Patients with rigid spine who sustain low-energy injuries may be 
prone to have a fracture and epidural hematoma, especially if they take 
anticoagulant medications. Imaging studies including MR and CT scans should be 
reviewed carefully to rule out any occult fracture. Urgent or early surgical 
hematoma drainage and instrumented fusion must be performed to achieve stability 
and functional recovery.