Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases

Prognostic factors and surgical outcomes of spontaneous spinal epidural haematoma: a systematic review and meta-analysis

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.

Spontaneous Spinal Epidural Hematoma Associated With Short-Term Dual Antiplatelet Therapy: A Case Report

Spinal epidural hematoma (SEDH), either spontaneous or traumatic, is a rare neurosurgical emergency. Typically, the natural history is a sudden onset of severe neck or back pain, associated with neurological deficit, either immediately or after a short period of the pain onset. MRI is the gold standard investigation. The mainstay of treatment is spinal decompression, in the form of laminectomy or hemilaminectomy, with the evacuation of the hematoma. The occurrence of SEDH has been strongly associated with coagulopathy, especially that induced by anticoagulant use. The association between SEDH and antiplatelet therapy has been scarcely reported in the literature. We report a case of spontaneous SEDH in a patient who was on dual antiplatelet therapy. Our case is unique because the patient had been using antiplatelet agents for only six weeks prior to this diagnosis. As antiplatelet agents are widely prescribed, physicians should be able to anticipate SEDH as a possible complication of dual antiplatelet therapy to facilitate early treatment and better outcomes.

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

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.

Hemorrhagic lesions associated with anticoagulant therapy: a pictorial review

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.

Spontaneous Spinal Epidural Hematoma Associated With the Use of Low-dose Aspirin in Elderly Patient

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.

Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols

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.].

Management of a Patient with a Thoracic Epidural After Accidental Clopidogrel Administration

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.