Surgical management of spinal intradural hematomas: illustrative cases.

backgroundSpinal intradural hematoma (SIH) is a rare condition with potential for permanent neurological deficit. SIH can be managed conservatively with serial imaging or surgically with lumbar drainage or open evacuation. We present 3 SIH cases managed with multiple surgical techniques, including a novel lumbar drainage-and-advancement technique, and review the literature. OBSERVATIONS: Patient 1 was a 35-year-old peripartum female with cauda equina syndrome after epidural analgesia. MRI revealed SIH at L4-5, necessitating urgent L3-S1 laminectomy and hematoma evacuation. Patient 2 was a 47-year-old male with bilateral lower extremity radiculopathy following posterior decompression and fusion for an L5 compression fracture. MRI revealed SIH extending from T3-L5. Focal decompression and lumbar drain placement with cranial advancement were performed for complete evacuation. Patient 3 was a 75-year-old male with urinary retention after restarting anticoagulation 4 days postlaminectomy for resection of a large synovial cyst at L4-5. MRI demonstrated a subdural collection suggestive of hygroma. A focal laminectomy with intrathecal decompression and a lumbar drain were used to completely evacuate the lesion. LESSONS: SIH management should be individualized. Focal decompression is effective for localized hematomas, while extensive, multilevel SIH may benefit from a lumbar drain with controlled cranial advancement, irrigation, and decompression. https://thejns.org/doi/10.3171/CASE25108.