Management of traumatic cervical epidural hematoma in patients on Xa-inhibitors: a case report and review of the literature.

BACKGROUND: Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This unique case of traumatic CEH represents an even smaller subset of these cases. Management varies by symptom presentation, mechanism of injury, and other contraindications. CASE PRESENTATION: This case presents a 32 year old African American female on an oral anticoagulant sustaining traumatic cervical hematoma after a motor vehicle collision. Patient complained of neck, abdominal, and back pain. Imaging revealed a cervical spinal hematoma at the level of C3-C6. This case discusses the management of CEH for the general population and in the setting of anticoagulation. CONCLUSION: Management of each case of CEH must be carefully considered and tailored based on their symptom presentation and progression of disease. As the use of anticoagulation including factor Xa inhibitors becomes more prevalent, there is greater need to understand the detailed pathophysiological aspect of the injuries. Targeted reversal agents such as Prothrombin Concentrate can be used for conservative treatment. Adjunct testing such as thromboelastogram can be used to help guide management.

Warfarin-related epidural hematoma: a case report.

Spinal epidural hematomas are rare, with trauma being the most common cause. Spinal epidural hematomas caused by coagulation dysfunction are even rarer; however, long-term warfarin therapy increases the risk. The clinical manifestations of spinal epidural hematoma are neurological deficits below the corresponding spinal cord segment level. Magnetic resonance imaging (MRI) is the preferred method for diagnosis, and the main treatment for epidural hematoma with typical symptoms is urgent decompression of the lumbar spine. We describe an almost 80-year-old female patient who received long-term oral warfarin therapy for atrial fibrillation. She developed sudden onset waist pain, and 2 days later, she developed pain and weakness in both lower limbs. Computed tomography (CT) of the thoracolumbar spine showed no obvious hematoma. Eight days after admission, contrast-enhanced CT of the thoracolumbar spine showed intraspinal hematomas at T5-T8 and T12-L2 levels. We performed T3-T7 laminectomy, T5-T8 hematoma removal, and spinal dural repair. The clinical symptoms did not improve significantly, postoperatively. The low incidence of spinal epidural hematoma after anticoagulation treatment means this condition is not recognized timely, and it is misdiagnosed easily. Clinicians should consider this condition when patients treated with anticoagulants have neurological deficits below a spinal segmental plane.

Spontaneous Spinal Epidural Hematoma in an Adult Patient with Complex Congenital Heart Disease.

Spontaneous spinal epidural hematoma (SSEH) is considered to be a relatively rare disease that can result in serious neurological sequelae. The pathogenesis and risk factors of SSEH are still unknown, and its differential diagnosis varies widely. Misdiagnosis with more common conditions such as stroke or aortic syndromes can occur. We report the case of a 27-year-old man who developed sudden upper back pain with no specific precipitant. Five days later, he visited our emergency department complaining of weakness in both lower limbs and dysuria. He had a history of intracardiac repair and a Blalock-Park procedure for an interrupted aortic arch and ventricular septal defect in infancy. Additionally, he had undergone an aortic root dilatation and aortic valve replacement at the age of 10 because of progression of aortic and supra-aortic stenosis and had received chronic anticoagulation and antiplatelet therapy with warfarin and aspirin, respectively. An emergency spine magnetic resonance imaging scan indicated a mass at the Th3-Th5 level with severe compression of the dural sac and the spinal cord. Emergency excision showed a spinal epidural hematoma. Mild postoperative gait disturbance and dysuria persisted, requiring rehabilitation and intermittent self-urethral catheterization. As patients with adult congenital heart disease have an increased risk of bleeding, they may be at risk of developing SSEH. However, this is the first report to describe such an association.

A rare case of non-traumatic spinal epidural hematoma in lumbar region associated with apixaban therapy.

Spontaneous spinal epidural hematoma (SSEH) is a very rare clinical entity with potential diagnostic difficulties and which can result in severe neurological deficit. The etiology of this rare condition is largely not known, but with potential predisposition in patients on anticoagulation medication. This includes the novel anticoagulants with direct inhibition of the factor Xa mechanism (DOACs). These medications are supposed to have more predictable pharmacokinetics with fewer severe haemorrhagic adverse events in comparison with standard warfarin therapy. However, in the last few years, an increasing number of case reports have been published of haemorrhage into the central nervous system. We present a case of non-traumatic spinal epidural hematoma in the lumbar region in a patient on chronic apixaban therapy. To the best of our knowledge, it is the first described SSEH in the lumbar region associated with apixaban therapy.

A Case Report of Slowly Evolving Epidural Hematoma After Lumbar Drain Removal Following Initiation of Clopidogrel Therapy.

Guidelines on the management of lumbar drain in patients receiving antithrombotic therapy are lacking, with American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines for regional anesthesia providing the best possible guidance for this scenario. However, the risk-benefits of placing a lumbar drain in the context of vascular surgery differ from placement of neuraxial blockade. One of the changes included in the recently published ASRA guidelines is that clopidogrel can be started on a patient with an indwelling neuraxial catheter. We report a case of slowly evolving epidural hematoma following the initiation of clopidogrel therapy in a patient with an indwelling lumbar drain.

Paraplegia Caused by Spontaneous Spinal Hemorrhage in a Patient Undergoing Rivaroxaban Therapy.

BACKGROUND Spinal hematomas can be post-traumatic, iatrogenic, or spontaneous. A spontaneous spinal hematoma is a rare finding, but one with very serious clinical implications. There are some risk factors linked to its occurrence, e.g. arteriovenous malformations, lumbar puncture, coagulopathy, neoplasms, or therapeutic anticoagulation. At present, only a few cases of spontaneous spinal hematoma (SSH) associated with new oral anticoagulants (NOACs) have been described, three of which were linked with rivaroxaban. CASE REPORT We report the case of an 82-year-old Caucasian woman with persistent atrial fibrillation treated with rivaroxaban, who presented to the Urology Department with acute-onset back pain which was thought to be due to urolithiasis. No kidney stones were found, but her creatinine serum level was elevated, so she was transferred to our clinic for further treatment. During hospitalization she quickly developed paraplegia with urine and stool retention. MRI was performed, and demonstrated an acute epidural hemorrhage in her thoracic and lumbar spine. The neurosurgeons disqualified this patient from surgical intervention due to the extent of the hematoma and its location. The patient was referred to the Neurology Department for treatment and rehabilitation, but, to the best of our knowledge, she did not recover her motor function. CONCLUSIONS Although rivaroxaban has been shown to be more effective than warfarin in stroke prevention in patients with atrial fibrillation, physicians must remember that its use also carries the risk of major bleeding. SSH occurrence should be taken into account in a patient taking NOACs who develops paraplegia, even if there is no history of trauma prior to admission.

[An atypical neuropathic pain; spontaneous epidural hemorrhage under oral anticoagulant therapy]. / Atipik nedenli nöropatik agri; oral antikoagülan tedavi altinda spontan epidural kanama.

Spontaneous epidural hemorrhage is one of the rare neuropathic pain etiologies. In this case, a 68-year-old patient, who had atrial fibrillation and cardioversion history, is evaluated for neuropathic pain due to spontaneous epidural hemorrhage that arose from oral anticoagulant therapy. As well as being unique in etiologic terms, we thought it is an uncommon occasion for management worth sharing.

[Two Cases of Cervical Epidural Hematoma that Developed during Oral Anti-Platelet Treatment and Achieved Satisfactory Outcomes Following Early Diagnosis and Treatment].

We report two cases of patients who developed cervical epidural hematoma while receiving oral anti-platelet agents and achieved satisfactory outcomes following early diagnosis and treatment. Both patients attained decompression within 12 hours of symptom onset and achieved independent gait at an early stage. Decompression was attained in a shorter amount of time(<6 hours)in case 1, and neurological symptoms rapidly and fully improved immediately following surgery. In contrast, sensory abnormality remained in case 2 despite early decompression(<12 hours.)Although there is a tendency to focus on improving motor function with regards to this condition, we found that the persistence of sensory abnormality affects the patient activities of daily living(ADL)more than expected. Based on these findings, we postulate that the reduction in the time until treatment completion is associated with better functional prognosis in patients who are receiving anti-platelet agents or have advanced motor paralysis.

Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain.

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).

Good outcomes after the delayed removal of an epidural hematoma: A case report.

RATIONALE: Epidural hematomas can develop following intrathecal puncture, spinal vascular malformation, or spontaneous hemorrhage. Prompt recognition of symptoms and referral to neurosurgical services are crucial for recovery. We report a rare case of delayed removal of an epidural hematoma that resulted in good patient outcomes. PATIENT CONCERNS: A 69-year-old woman weighing 58 kg presented with back pain that had persisted for 12 years. Her medical history was notable for hypertension. Cervical computed tomography angiography indicated a giant abdominal aortic aneurysm measuring 11.58 × 17.34 × 13.00 cm in her abdominal cavity. Stent graft implantation was scheduled by the interventional therapy group to treat her abdominal aortic aneurysm under single-dose spinal anesthesia. Postoperatively, the patient complained of numbness and swelling of her lower extremities, with progressive paralysis developing in both legs accompanied with sensory disturbances. DIAGNOSES: Delayed magnetic resonance imaging detected an epidural hematoma. INTERVENTIONS: Eighty hours after the onset of sensorimotor symptoms, lumbar decompression and removal of the hematoma were performed via laminectomy under general anesthesia. OUTCOMES: The patient was discharged 2 months after the operation with a 3/5 score on the Muscle Strength Grading System. LESSONS: Laminectomy may be effective in achieving a good prognosis despite a considerable delay in diagnosis.

Epidural Hematoma Following Interlaminar Epidural Injection in Patient Taking Aspirin.

OBJECTIVE: We present a case report of a patient who developed an epidural hematoma following an interlaminar epidural steroid injection with no risk factors aside from old age and aspirin use for secondary prevention. CASE REPORT: A 79-year-old man developed an epidural hematoma requiring surgical treatment following an uncomplicated interlaminar epidural steroid injection performed for neurogenic claudication. In the periprocedural period, he continued aspirin for secondary prophylaxis following a myocardial infarction. CONCLUSIONS: For patients taking aspirin for primary or secondary prophylaxis, the American Society of Regional Anesthesia and Pain Medicine antiplatelet and anticoagulation guidelines for spine and pain procedures recommend a shared assessment and risk stratification when deciding to hold the medication for intermediate-risk neuraxial procedures. Cases such as this serve to highlight the importance of giving careful consideration to medical optimization of a patient even when a low- or intermediate-risk procedure is planned.

Acute and Rapid Development of Spontaneous Spinal Epidural Hematoma Associated with Combined Aspirin-Dipyridamole Therapy: A Case Report.

CASE: Spontaneous spinal epidural hematoma (SSEH) is a known, although rare, clinical entity that may be challenging to diagnose. This case report describes the rapid development of a large SSEH in an elderly patient on aspirin-dipyridamole combination therapy after she shifted her position in bed. Magnetic resonance imaging obtained 4 hours after the onset of symptoms demonstrated a large spinal epidural hematoma that extended from T4 to L1. CONCLUSION: With early diagnosis, the patient was successfully treated with a laminectomy and evacuation of the hematoma, and there was full neurological recovery.

Prevention of Thromboembolic Complications After Spine Surgery by the Use of Low-Molecular-Weight Heparin.

OBJECTIVE: This study aimed to evaluate the effectiveness and safety of the use of low-molecular-weight heparin (LMWH) in the prevention of thromboembolic complications after spine surgery. METHODS: We conducted a retrospective study on 2 groups of patients receiving spine surgery. A total of 947 patients admitted for surgery from July 2009 to June 2012 were administered therapeutic dose of LMWH daily after the surgery (therapeutic group). Another 814 patients enrolled from July 2006 to June 2009 were not given any heparin treatment (control group). The wound drainage volume, the incidence rate of thrombosis and thromboembolic complications, and the occurrence of bleeding complications in 2 groups were statistically compared. RESULTS: The therapeutic group showed a lower rate of postsurgery thromboembolic complications when compared with the control group (therapeutic group, 0.21%; control group, 1.6%; P = 0.002). Among the individual type of complications, the occurrence of cerebral infraction was the most significantly reduced (P = 0.005). The overall rate of bleeding complications was higher in the therapeutic group compared with the control group, and the difference was marginally insignificant (therapeutic group, 1.8%; control group, 0.74%; P = 0.051). CONCLUSIONS: The use of LMWH significantly decreases the incidence of thrombosis and thromboembolic complications after spine surgery, but increase the incision bleeding, leading to an elevated risk of symptomatic spinal epidural hematoma.