Acute nontraumatic spinal intradural hematoma in a patient on warfarin.

BACKGROUND: Nontraumatic spinal intradural extramedullary hematomas are extremely rare. When they occur, they can rapidly lead to spinal cord or cauda equina compression and have devastating consequences. OBJECTIVE: The aim here was to report a case of this rare phenomenon and discuss the etiology, imaging, management, and outcome of intradural hematomas. CASE REPORT: We describe the case of a 76-year-old man on warfarin therapy who presented with severe lower back pain and flaccid paraparesis. Blood tests revealed an international normalized ratio of 6.0. A magnetic resonance imaging result suggested an intradural hematoma extending from L1 to L4 and compressing the spinal cord and cauda equina. Emergency surgical decompression revealed an extensive intradural extramedullary hematoma, which was evacuated. The patient showed only minor neurologic improvement 6 months postoperatively. CONCLUSIONS: Coagulopathy-induced spinal hemorrhage should be included in the differential diagnosis for patients presenting with signs of acute spinal cord compression.

Treatments for osteoporosis in people with a disability.

The morbidity from osteoporotic fractures for people with a disability is considerable because of the increased risk of medical complications, loss of independence and mobility, and prolonged hospitalization. The frequency with which low bone mineral density occurs in people with a disability is now well recognized, and professionals have a greater awareness of the need to investigate bone mineral density levels with a view to preventing fragility fractures. After patients with osteoporosis are identified, the challenge is to treat them appropriately. This article reviews the physical and pharmacologic measures that have been researched in the prevention and treatment of low bone mineral density in people with a disability.

A study of bone mineral density in adults with disability.

OBJECTIVES: To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories. DESIGN: Cross-sectional study. SETTING: National Rehabilitation Hospital, Dublin, Ireland. PARTICIPANTS: Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores. RESULTS: Mean age +/- SD of participants was 48.7+/-15.6 years. Vitamin D deficiency, 25-OHD level 50 nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72 nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of -1 or less but more than -2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of -2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (beta=.152, P=.007; beta=-.191, P=.001, respectively) and total proximal femur (beta=.170, P=.001; beta=-.216, P<.001, respectively). CONCLUSIONS: Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.