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Abu-Abaa M, Jumaah O, Mousa A, Al-Qaysi G. A Spontaneous Spinal Epidural Hematoma Secondary to Long-Term Low-Dose Aspirin and Clopidogrel Use: A Case Report. Cureus 2023; 15:e34537. [PMID: 36879714 PMCID: PMC9985069 DOI: 10.7759/cureus.34537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
The association between antiplatelet agents such as aspirin, clopidogrel, and ticlopidine and spontaneous spinal epidural hematoma is based on multiple case reports in the literature. Here, we present the case of a 76-year-old male patient who presented with acute low back pain associated with sudden-onset paralysis of the lower extremities. His past medical history was remarkable for coronary artery disease with a stent placement history on dual antiplatelet therapy including low-dose aspirin and clopidogrel. An extensive posterior thoracolumbar epidural hematoma was seen on the imaging test, and rapid clinical improvement was evident early during his presentation. This prompted a conservative approach that led to complete neurological recovery. This case is in line with limited English-language literature evidence that suggests a possible association between spontaneous spinal epidural hematoma and antiplatelet agents. We aim to enhance clinicians' awareness of this clinical entity, association, presentation, and management.
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Affiliation(s)
- Mohammad Abu-Abaa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Omar Jumaah
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Aliaa Mousa
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
| | - Ghassan Al-Qaysi
- Internal Medicine, Capital Health Regional Medical Center, Trenton, USA
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2
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Vastani A, Baig Mirza A, Khoja AK, Bartram J, Shaheen S, Rajkumar S, China M, Lavrador JP, Bleil C, Bell D, Thomas N, Malik I, Grahovac G. Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:21. [PMID: 36538111 DOI: 10.1007/s10143-022-01914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Spontaneous spinal epidural haematoma (SSEH) is a rare disease defined as blood accumulation within the vertebral epidural space without a cause identified, which can lead to severe neurological deficits. We aim to provide a comprehensive understanding of the prognostic factors affecting surgical outcomes in true SSEH and propose a critical time frame for operative management. A systematic literature search was performed and registered, using OVID Medline and EMBASE, in line with the PRISMA guidelines. Relevant demographic, clinical, surgical, and outcome data were extracted. The ASIA scale was uniformly used throughout our systematic review. Statistical analysis was performed via logistic regression. Of the 1179 articles examined, we included 181 studies involving 295 adult patients surgically treated for SSEH. SSEH were most commonly found in the cervicothoracic spine, with 2-4 spinal segments most commonly involved. Multivariable logistic regression model showed that the following factors were statistically significant in the post-operative outcome: operation type (P = 0.024), pre-operative neurologic status (P < 0.001), use of warfarin (P = 0.039), and operative interval (P = 0.006). Our retrospective analysis confirms the reversibility of severe neurological deficits after surgical intervention, with a prognosis of post-operative outcomes determined by the use of warfarin, pre-operative ASIA grade, and above all surgical evacuation within 12 h.
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Affiliation(s)
- Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK.
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Abbas Khizar Khoja
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - James Bartram
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Safwan Shaheen
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Shivani Rajkumar
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Musa China
- Division of Medicine, University College London (UCL), London, UK
| | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Cristina Bleil
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - David Bell
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Irfan Malik
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Gordan Grahovac
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
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Musha Y, Kinjo S, Ishimine Y, Takesue Y, Sakamoto T, Ito K. Therapeutic strategy for acute spinal cord paralysis by epidural hematoma derived from the application of non-operative observation and the optimal timing to convert to surgical intervention. J Clin Neurosci 2021; 86:242-246. [PMID: 33775335 DOI: 10.1016/j.jocn.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/30/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
Some cases of acute spinal cord paralysis by epidural hematoma have made complete recovery through natural progression. This group cannot be ignored in choosing a therapy. We have considered the applications of non-operative observation and the optimal timing to convert to surgical intervention. Of the 454 cases reported, cases that were of trauma/post-operative, undergone epidural block, lumbosacral level, paralysis-free, were excluded. 10 clinical items were identified as factors related to the outcome of therapy, and a total of 142 cases (73 surgical and 69 non-surgical/observation cases) which included all items in its record, were extracted for this study. 104 cases that made complete recovery from spinal paralysis (CR) includes 65 cases without surgical intervention (NOP-CR). Using "paralysis recovery start time (PRST)", ROC analysis was conducted to show the diagnostic time needed to detect the cases of CR and NOP-CR. Clinical characteristics of CR and NOP-CR were identified using multiple logistics regression analysis. CR probability were higher at PRST < 15 h from the onset and NOP-CR was even higher at < 11 h. Three clinical items: incomplete motor paralysis, no use of anti-coagulant therapy, and PRST within 15 h were found to be the characteristics of CR and NOP-CR. The case with all 3 items; especially PRST within 11 h from onset, is applicable to non-operative observation. Immediate surgical intervention at 6-hours is recommended in cases that presented with unchanged complete motor paralysis. Observation treatment is discontinued and converted to surgery if motor usefulness is not regained at 15-hours.
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Affiliation(s)
- Yoshiro Musha
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
| | - Sumito Kinjo
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Youhei Ishimine
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Yuya Takesue
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Tetsuo Sakamoto
- Department of Orthopaedic Surgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
| | - Keisuke Ito
- Department of Neurosurgery, Toho University Ohashi Medical Center, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
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Hayden AM, Arora L, Hobbs RA, Sharafuddin MJ. The Use of Cangrelor Infusions After Endovascular Aortic Repair With Prophylactic Lumbar Drain Placement. J Cardiothorac Vasc Anesth 2020; 35:3723-3726. [DOI: 10.1053/j.jvca.2020.11.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/11/2022]
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Çankaya BY, Alper F, Karaman A, Akgün M. Hemorrhagic lesions associated with anticoagulant therapy: a pictorial review. J Thromb Thrombolysis 2020; 51:1067-1077. [PMID: 33034813 DOI: 10.1007/s11239-020-02305-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
Anticoagulant therapy is a treatment that can cause bleeding complications in many anatomical structures. Intracranial, intramuscular and intraabdominal bleeding are internal bleeding that can be secondary to anticoagulated therapy. The prognosis of these hemorrhages can be very good, depending on the anatomical region involved, or they can be fatal. Early recognition of especially intracranial and renal hemorrhages is important for prognosis. For diagnosis, CT and / or MRI should be evaluated according to the region. Internal bleeding should be kept in mind in cases such as sudden hemoglobin decrease or change in consciousness during anticoagulant therapy.
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Affiliation(s)
- Bahar Yılmaz Çankaya
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey.
| | - Fatih Alper
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Adem Karaman
- Department of Radiology, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
| | - Metin Akgün
- Department of Pulmonary Diseases, School of Medicine, Atatürk University, 25240, Erzurum, Turkey
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Spontaneous Spinal Epidural Hematoma Associated With the Use of Low-dose Aspirin in Elderly Patient. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e059. [PMID: 30656250 PMCID: PMC6324892 DOI: 10.5435/jaaosglobal-d-18-00059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Spontaneous spinal epidural hematoma is a rare condition defined by bleeding in the epidural space of the spine with no identifiable causes such as trauma, vascular malformation, or bleeding disorders. This is a case of a 79-year-old woman with a medical history of diabetes mellitus, dyslipidemia, and hypertension presented with the sudden onset of severe thoracolumbar back pain associated with weakness and numbness in her bilateral lower limb. Examination of the lower limb showed bilateral lower limb motor and sensory deficits. Laboratory investigations showed normal results. MRI showed posterior extradural intraspinal hematoma from T11 to L3 vertebrae. Patient underwent right hemilaminectomy and posterior decompression of T12 and L1 vertebrae to evacuate the hematoma. Postoperatively, her neurologic complications improved gradually. Decision was made not to restart aspirin. On follow-up at 1 year, the patient had complete recovery of neurologic complications of both lower limb and had no recurrence of bleeding. In short, this is a case of spontaneous spinal epidural hematoma associated with long-term use of low-dose aspirin in an elderly patient requiring surgical evacuation of hematoma with good functional outcome after the surgery. Therefore, aspirin should be prescribed cautiously especially to elderly patients.
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7
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Okazaki T, Nakagawa H, Hayase H, Irie S, Inagaki T, Saito O, Yamashina M, Nagahiro S, Saito K. Idiopathic and Chronic Epidural Hematoma in the Lumbar Spine: A Case Report and Review of Literatures. Neurol Med Chir (Tokyo) 2018; 58:138-144. [PMID: 29415912 PMCID: PMC5929923 DOI: 10.2176/nmc.cr.2017-0052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Spontaneous and chronic epidural hematoma (SSEH) in the lumbar spine is rare, and idiopathic and chronic SSEH in the lumbar spine is extremely rare disease. Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. Definitive guidelines for management of this condition are not clear and surgical total evacuation was performed in most of the cases. Some authors reported the epidural bleeding originates in the rupture of Batson’s plexus due to a rise in intra-abdominal pressure, but the mechanism is not clearly clarified. We report a surgical case of idiopathic and chronic SSEH. A 61-year-old woman suffered a sudden onset of severe lumbar pain during sleep. She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5. This patient underwent the partial evacuation of the hematoma with partial hemilaminectomy on left at L2/3, resulting in immediate pain relief and resolution of symptoms and almost absorption of the hematoma within 1 week of the procedure. We presented this rare case and reviewed idiopathic and chronic epidural hematoma in the lumbar spine.
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Affiliation(s)
- Toshiyuki Okazaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital.,Department of Neurosurgery, Tokushima University
| | | | - Hitoshi Hayase
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Shinsuke Irie
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Toru Inagaki
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | - Osamu Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
| | | | | | - Koji Saito
- Department of Neurosurgery, Kushiro Kojinkai Memorial Hospital
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Yamaguchi K, Mathew J, Lhi JM, Park DY. Acute and Rapid Development of Spontaneous Spinal Epidural Hematoma Associated with Combined Aspirin-Dipyridamole Therapy: A Case Report. JBJS Case Connect 2017; 7:e19. [PMID: 29244699 DOI: 10.2106/jbjs.cc.16.00134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Kent Yamaguchi
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, California
| | - Justin Mathew
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - James M Lhi
- University of Southern California School of Pharmacy, Los Angeles, California
| | - Don Young Park
- Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, California
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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McCunniff PT, Young ES, Ahmadinia K, Kusin DJ, Ahn UM, Ahn NU. Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols. Orthopedics 2016; 39:e695-700. [PMID: 27111080 DOI: 10.3928/01477447-20160419-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/10/2016] [Indexed: 02/03/2023]
Abstract
There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].
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11
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Fu CF, Zhuang YD, Chen CM, Cai GF, Zhang HB, Zhao W, Ahmada SI, Devi RD, Kibria MG. Spontaneous spinal epidural hematoma management with minimally invasive surgery through tubular retractors: A case report and review of the literature. Medicine (Baltimore) 2016; 95:e3906. [PMID: 27367986 PMCID: PMC4937900 DOI: 10.1097/md.0000000000003906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To report a minimally invasive paraspinal approach in the treatment of a case of spontaneous spinal epidural hematoma (SSEH). We additionally aim to review the relevant literature to enhance our knowledge of this disease. SSEH is an uncommon but potentially catastrophic disease. Currently, most appropriate management is emergence decompression laminectomy and hematoma evacuation. An 81-year-old woman was admitted to the neurology department with a chief complaint of bilateral numbness and weakness of the lower limbs and difficulty walking for 4 days with progressive weakness developed over the following 3 days accompanied with pain in the lower limbs and lower back. No history of trauma was reported. Magnetic resonance imaging of the thoracolumbar spine demonstrated an epidural hematoma extending from T-12 to L-5 with thecal sac and cauda equina displacement anterior. The patient was treated in our department with a minimally invasive approach. This operation method had been approved by Chinese Independent Ethics Committee. Three months following the operation, the patient had regained the ability to walk with the aid of a cane and myodynamia tests revealed normal results for the left lower limb and a 4/5 grade for the right limb. Importantly, no complications were exhibited from the surgical operation. The minimally invasive paraspinal approach through tubular retractors is demonstrated here as an effective alternative method for the treatment of SSEH.
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Affiliation(s)
| | | | - Chun-Mei Chen
- Department of neurosurgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Correspondence: Chun-Mei Chen, Department of neurosurgery, Fujian Medical University Union Hospital, NO.29, Xinquan Road, Fuzhou, Fujian, 350000, China (e-mail: ); Gang-Feng Cai, Department of neurosurgery, Chinese people's liberation army 180 hospital, Quanzhou 362000, China (e-mail: )
| | - Gang-Feng Cai
- Department of neurosurgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- Correspondence: Chun-Mei Chen, Department of neurosurgery, Fujian Medical University Union Hospital, NO.29, Xinquan Road, Fuzhou, Fujian, 350000, China (e-mail: ); Gang-Feng Cai, Department of neurosurgery, Chinese people's liberation army 180 hospital, Quanzhou 362000, China (e-mail: )
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12
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Mohammed N, Shahid M, Haque M, Qureshi M, Hoey ETD. Spontaneous spinal epidural haematoma mimicking acute coronary syndrome. Quant Imaging Med Surg 2016; 5:925-7. [PMID: 26807374 DOI: 10.3978/j.issn.2223-4292.2015.01.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Spontaneous spinal epidural hematoma (SSEH) is an acute neurological emergency which carries significant morbidity unless diagnosed and treated in a timely fashion. Some cases of SSEH are idiopathic but there is a well-recognised association with deranged coagulation and abnormalities of clotting. In recent years there has been increasing availability of novel anti-platelet agents, often prescribed in the setting of suspected acute coronary syndromes (ACS) and following percutaneous coronary interventions and these agents also present an increased risk of SSEH. We present a case of SSEH following an acute presentation with chest pain and treatment with dual anti-platelet therapy.
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Affiliation(s)
- Noor Mohammed
- 1 Department of Cardiology, 2 Department of Radiology, Heart of England NHS Trust, Birmingham B9 5SS, UK
| | - Muhammad Shahid
- 1 Department of Cardiology, 2 Department of Radiology, Heart of England NHS Trust, Birmingham B9 5SS, UK
| | - Munirul Haque
- 1 Department of Cardiology, 2 Department of Radiology, Heart of England NHS Trust, Birmingham B9 5SS, UK
| | - Masood Qureshi
- 1 Department of Cardiology, 2 Department of Radiology, Heart of England NHS Trust, Birmingham B9 5SS, UK
| | - Edward T D Hoey
- 1 Department of Cardiology, 2 Department of Radiology, Heart of England NHS Trust, Birmingham B9 5SS, UK
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Hah JM, Noon K, Gowda A, Brun C. Management of a Patient with a Thoracic Epidural After Accidental Clopidogrel Administration. ACTA ACUST UNITED AC 2016; 5:18-20. [PMID: 26171737 DOI: 10.1213/xaa.0000000000000165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of accidental clopidogrel administration in a patient receiving ongoing epidural analgesia postoperatively. The epidural catheter was removed 7 hours after the clopidogrel dose without incident. The onset of inhibition of adenosine diphosphate-induced platelet aggregation in healthy individuals has been reported at 12 to 24 hours after administration of a single 75-mg dose of clopidogrel. This case demonstrates the importance of understanding clopidogrel's pharmacology to avoid ordering unnecessary tests, which may delay catheter removal. Consideration of appropriate testing and limitations in the context of unintentional antiplatelet administration with indwelling neuraxial catheters is discussed.
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Affiliation(s)
- Jennifer M Hah
- From the *Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, California; and †Department of Anesthesiology, Veterans Affairs Palo Alto, Palo Alto, California
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Bhat KJ, Kapoor S, Watali YZ, Sharma JR. Spontaneous epidural hematoma of spine associated with clopidogrel: A case study and review of the literature. Asian J Neurosurg 2015; 10:54. [PMID: 25767588 PMCID: PMC4352641 DOI: 10.4103/1793-5482.151521] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is an uncommon neurological emergency which can present with the features ranging from simple back pain with radiculopathy to complete paraplegia or quadriplegia depending on the site and severity of the compression. Spinal hemorrhage associated with anti-platelet drugs is rarely seen. We report a case of SSEH in a 68-year-old hypertensive male who was on a low dose clopidogrel for secondary stroke prophylaxis and presented with bilateral lower limb paralysis, preceeded by severe back bain. A spinal magnetic resonance imaging scan was performed which revealed a posterior epidural hematoma of the thoraco-lumbar spine. To the best of our knowledge, not more than four cases of clopidogrel related spinal epidural hematoma have been reported. Emergent decompressive laminectomy was done within 4 hours of the presentation with excellent clinical outcome. Clinicians should, therefore, consider the remote risk of SSEH in hypertensive patients who are on anti-platelet drugs as early decompressive laminectomy and evacuation of the hematoma minimizes the permanent neurological damage.
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Affiliation(s)
- Khalid Javid Bhat
- Department of Internal Medicine, ASCOMS and Hospitals, Sidhra, Jammu, India
| | - Sidhart Kapoor
- Department of Internal Medicine, ASCOMS and Hospitals, Sidhra, Jammu, India
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15
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Rajz G, Cohen JE, Harnof S, Knoller N, Goren O, Shoshan Y, Fraifeld S, Kaplan L, Itshayek E. Spontaneous spinal epidural hematoma: The importance of preoperative neurological status and rapid intervention. J Clin Neurosci 2015; 22:123-8. [DOI: 10.1016/j.jocn.2014.07.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/05/2014] [Indexed: 12/17/2022]
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Akhavan-Sigari R, Rohde V, Abili M. Continuation of medically necessary platelet aggregation inhibitors - acetylsalicylic acid and clopidogrel - during surgery for spinal degenerative disorders: Results in 100 patients. Surg Neurol Int 2014; 5:S376-9. [PMID: 25289165 PMCID: PMC4173210 DOI: 10.4103/2152-7806.139675] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/30/2014] [Indexed: 01/30/2023] Open
Abstract
Background: Patients undergoing spinal surgery while under anticoagulation therapy are at risk of developing bleeding complications, even though lower incidences have been reported for joint arthroplasty surgery. There is a gap in the medical literature examining the incidence of postoperative spinal bleeding in patients who were under anticoagulation medication at the time of surgery. Methods: We prospectively followed a consecutive cohort of 100 patients (58 male, 42 female) undergoing spinal surgery. The average patient age was 48.7 years and the minimum follow up time was 12 months. Diagnosis was lumbar spinal stenosis in 20, herniated lumbar discs in 63, degenerative cervical disc disease in 3, and cervical disc herniation in 14 cases. In our study, platelet aggregation inhibitors (clopidogrel and/or acetylsalicylic acid) were given for the treatment of cardiovascular and cerebrovascular thrombotic events, to reduce risk of stroke in patients who have had transient ischemia of the brain or acute coronary syndrome, and as secondary prevention of atherosclerotic events (fatal or nonfatal myocardial infarction (MI). A cessation of anticoagulants (acetylsalicylic acid or clopidogrel) in our patients in the peri- and postoperative period was contraindicated. Results: Sixty-three patients were on both clopidogrel and acetylsalicylic acid and 37 on acetylsalicylic acid only. None of the patients suffered any postoperative bleeding complication. Three patients suffered postoperative wound dehiscence and one patient had an infection that required reoperation. Conclusion: The question of whether preoperative platelet aggregation inhibitors must be stopped before elective spinal surgery has never been answered in the literature. In our prospective series, we have found no increase in the risk of postoperative spinal bleeding with the use of clopidogrel or acetylsalicylic acid. This finding suggests that spine surgery can be done without stopping anticoagulation. Lacking specific guidelines, each patient should be treated on an individual basis, and the potential benefits of anticoagulation should be compared with the potential risks (risk–benefit ratio).
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Affiliation(s)
- Reza Akhavan-Sigari
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University Göttingen, Germany
| | - Mehdi Abili
- Department of Neurosurgery, Mashhad University of Medical Sciences, Taleghani Hospital, Mashhad, Iran
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Wang L, Liu G, Subramaniam S, Wong TAKW, Kumar N. Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases. J Orthop Surg (Hong Kong) 2012; 20:386-90. [PMID: 23255653 DOI: 10.1177/230949901202000326] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report 2 cases of spontaneous spinal epidural haematoma after antiplatelet treatment. One patient was on ticlodipine therapy and the other was on aspirin and clopidogrel. Both diagnoses were made using magnetic resonance imaging. One patient underwent multilevel laminectomies and posterior spinal fusion within 24 hours of symptom onset and achieved complete neurological recovery. The other underwent unilateral hemilaminectomies 40 hours after symptom onset and did not show neurological improvement. A high index of suspicion is needed for patients presenting with severe lower back pain and rapid neurological deterioration, especially in those on antiplatelet therapy. Urgent spinal cord decompression and epidural haematoma cord evacuation may provide more favourable outcome.
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Affiliation(s)
- Lushun Wang
- Department of Orthopaedics, National University Hospital, Singapore
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18
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Abstract
BACKGROUND Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates. METHOD This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis. RESULTS Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism. CONCLUSIONS The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.
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Affiliation(s)
- Mitchell J Steele
- Wollongong Hospital, 4 Mansion Pt Road, Grays Point, Sydney, NSW 2232, Australia.
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Fedor M, Kim ES, Ding K, Muizelaar JP, Kim KD. Spontaneous Spinal Epidural Hematoma: A Retrospective Study on Prognostic Factors and Review of the Literature. KOREAN JOURNAL OF SPINE 2011; 8:272-82. [PMID: 26064145 PMCID: PMC4461739 DOI: 10.14245/kjs.2011.8.4.272] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 12/20/2011] [Accepted: 01/05/2012] [Indexed: 12/26/2022]
Abstract
Objectives The spontaneous spinal epidural hematoma (SSEH) is a rare clinical entity. Patients typically present with sudden onset back pain followed by neurological deficits. Methods Diagnosis of SSEH is usually made with MRI and standard treatment is surgical evacuation. In 1996, Groen published the most comprehensive review on the SSEH in which he analyzed 333 cases. We review 104 cases of SSEH presented in the English literature since the last major review and add three of our own cases, for a total of 107 cases. Results Our patients presented with back pain and neurologic deficits. Two made excellent functional recovery with prompt surgical decompression while one continued to have significant deficits despite evacuation. Better postoperative outcome was associated with less initial neurological dysfunction, shorter time to operation from symptom onset and male patients. Conclusion We discuss the etiology of SSEH and report current trends in diagnosis, treatment, and outcome.
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Affiliation(s)
- Mark Fedor
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Eric S Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kai Ding
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, USA
| | - J Paul Muizelaar
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis Medical Center, USA
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Abstract
UNLABELLED Spontaneous spinal epidural hematoma is a rare disorder. We present a case of a 55-year-old man who was awakened by severe pain in the neck and shoulders and inability to move his arms and legs. He was admitted to the clinic as an emergency. His physical status showed no abnormalities. The local status presented with roughly expressed cervical vertebral syndrome. Neurological examination found quadriplegia of acute onset. Distal parahypesthesia with sensory level at the nipples was found. The patient suffered urine retention. Laboratory blood tests showed no coagulation disorder. Spiral computed tomography of the cervical region was performed. The CT image revealed a muff-shaped acute epidural hematoma around the cervical dural membrane with lower thickness on the right side and levels from C2 to C4. Emergency right-sided hemilaminectomy of C3 vertebra was performed. A hard blood clot forming acute epidural hematoma was removed. The patient recovered completely for ten days after the surgery. CONCLUSIONS In sudden occurrence of neck pain associated with neurological deficit in the arms spontaneous cervical epidural hematoma should be suspected. Spiral scanner and magnetic resonance are imaging techniques of choice in these patients. The favorable outcome of the disease depends on the prompt diagnosis and emergency removal of the hematoma.
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Qiu W, Sun W, Guo C, Wu Z, Ding M, Shen H. Diagnosis and microsurgery of symptomatic spontaneous spinal epidural hematoma. Ir J Med Sci 2010; 180:241-5. [PMID: 20680702 DOI: 10.1007/s11845-010-0533-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 07/08/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Symptomatic spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of cord compression that needs emergent treatment. Without effective management of the symptomatic SSEH, irreversible severe spinal injury would be possible. OBJECTIVES We aimed to investigate the diagnosis and surgical management of symptomatic SSEH. METHODS Five cases of symptomatic SSEH with favorable neurological recovery after emergent microsurgery were prospectively analysed. RESULTS The main clinical presentations were root pain and palsy. The main manifestations of MRI were long-segment epidural lesions of high intensity on T1- and T2-weighted images without enhancement. Laminectomy via posterior approach and hematoma removal were undergone for all patients. All patients achieved full neurological recovery without complications. CONCLUSIONS MRI manifestation assisted with the main clinical symptoms may aid the preoperative diagnosis of SSEH, and the delay in obtaining preoperative Digital subtraction angiography is worthwhile, especially for those with progressive neurological deterioration.
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Affiliation(s)
- W Qiu
- Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, Hangzhou, 310015, China
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Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64-101. [PMID: 20052816 DOI: 10.1097/aap.0b013e3181c15c70] [Citation(s) in RCA: 659] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.
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Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerkranser M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010; 54:16-41. [PMID: 19839941 DOI: 10.1111/j.1399-6576.2009.02089.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.
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Affiliation(s)
- H Breivik
- Section for Anaesthesiology and Intensive Care Medicine, University of Oslo, Rikshospitalet, Oslo, Norway.
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Dimou J, Jithoo R, Morokoff A. Spontaneous spinal epidural haematoma in a geriatric patient on aspirin. J Clin Neurosci 2010; 17:142-4. [DOI: 10.1016/j.jocn.2009.03.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 03/11/2009] [Indexed: 01/28/2023]
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Spontaneous spinal epidural hematoma presenting with quadriplegia after sit-ups exercise. Am J Emerg Med 2009; 27:1170.e3-7. [DOI: 10.1016/j.ajem.2009.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 01/07/2009] [Indexed: 11/22/2022] Open
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Spontaneous spinal epidural hematoma: An urgent complication of adding clopidogrel to aspirin therapy. J Neurol Sci 2009; 285:254-6. [DOI: 10.1016/j.jns.2009.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/20/2022]
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Spontaneous Spinal Epidural Hematoma in Pregnancy Associated With Using Low Molecular Weight Heparin. Obstet Gynecol 2009; 113:532-533. [DOI: 10.1097/aog.0b013e31818f52d1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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