Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants.

OBJECTIVE: Spine surgeons increasingly encounter acute spinal pathologies in patients treated with direct oral anticoagulants (DOACs), but only limited data on the management of these patients are currently available. METHODS: We retrospectively analyzed patients who presented to our department with acute spinal pathology during treatment with DOAC and who required urgent surgical therapy. Patient characteristics and treatment modalities were studied, with specific focus on the management of hemostasis and surgical therapy. Furthermore, we analyzed 19 cases of spinal emergencies during DOAC treatment reported in the literature. RESULTS: A total of 12 patients were identified and included in the present analysis. Patients suffered from acute spinal cord compression caused by spinal tumor manifestation (n = 5), empyema (n = 4), degenerative spinal stenosis (n = 1), hematoma (n = 1), and vertebral body fracture/dislocation (n = 2). All patients underwent emergency surgical treatment. Prohemostatic substances were administered perioperatively in 10 patients (83%) and included administration of prothrombin complex concentrates (83%), tranexamic acid (17%), and transfusion of platelets (8%). A total of 9 patients (75%) showed postoperative improvement of neurologic symptoms, and the in-hospital mortality in this patient cohort was 17%. CONCLUSIONS: Emergency spine surgery is feasible and should be considered in patients on treatment with DOAC. The (low) risk of intraoperative bleeding complications has to be weighed against the risk of permanent disability if surgical decompression is delayed. Administration of prothrombin complex concentrates and tranexamic acid may improve the coagulation before surgery, especially in cases of unavailable specific antidotes.

Vascular and parameningeal infections of the head and neck.

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.

A Retrospective Analysis on the Prognostic Factors of Brain Abscess

The medical records of fifty-seven patients uith intracranial abscess which had been admitted to the departrnents of neurology, neurosurgery, otolaryngology and pediatrics. In Seoul National University Hospital from 1983 to 1992 were reviewed. Mean age was 31.4 years, ranging from 3 to 66 vears. Male predominated with the ratio of 2.6: 1. Common predisposing conditions were hearrt disease, parameningeal infection such as chronic otitis media, paranasal sinusitis, pulmonary infections in order of frequency. Primary focus was not determined in 16% of cases. A wide range of organisms were encountered and aerobes were more frequently cultivated than anaerobes. In 56% of cases. Pathogens were not confirmed. The use of preoperative antibiotics was not significantly correlated with sterile cultures: Initial symptoms and signs uere usually nonspecific; headache in 89%, fever in 53%. Nausea and vomiting in 54%. Altered consciousness in 39%. Computed tomography was the most accurate and rapid diagnostic tool, and serial follow-up during the treatment was helpful in knowing whether the response to several treatment modalities was good or not. Of the fifty-seven cases, twenty-seven patients were operated; 17 patients underwent aspiration of the abscesses, and ten patients received resection of abscesses. Sixty three percents of surviving patients suffered from neurologic sequelae; most commonly epilepsy in 50%. The mortality rate among all treated patients was significantly related to the initial consciousness level and the number ol the abscesses, but not to the size ol lesion. Identification of organism, age or sex. Although non-surgical therapy is appropriate n some selected patients, surgical intervention should be considered, when the consciousness level deterates or the CT findings are aggravated after full dose of combination antibiotics.