Spontaneous epidural haematoma presenting as cord compression in a patient receiving clopidogrel

A Spontaneous Spinal Epidural Hematoma Secondary to Long-Term Low-Dose Aspirin and Clopidogrel Use: A Case Report

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.

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.

Spontaneous epidural hematoma of spine associated with clopidogrel: A case study and review of the literature

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.

Spinal subarachnoid hematoma as a complication of an intramuscular stimulation : case report and a review of literatures

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

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

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.

Diagnosis and microsurgery of symptomatic spontaneous spinal epidural hematoma

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.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

OBJECTIVE

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery.

SUMMARY AND BACKGROUND DATA

Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible.

CLINICAL REPORT

A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma.

CONCLUSION

Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Acute spontaneous spinal epidural hematoma: an important differential diagnosis in patients under clopidogrel therapy

BACKGROUND CONTEXT

Spontaneous spinal epidural hematoma (SSEH) is an infrequent spinal pathology. Although it is related to numerous risk factors, its etiology remains unclear.

PURPOSE

The aim of this article was to review the most important data in the literature about SSEH and to propose clopidogrel (Plavix) therapy as a risk factor.

STUDY DESIGN

Case report.

METHODS

A 79-year-old woman was hospitalized in our unit with posterior thoracic pain and urinary retention of 72 hours duration. A clinical history was taken, and laboratory and imaging tests were performed. Urgent surgical decompression was performed, showing an epidural hematoma. Postoperative bacteriological cultures were negative, and microscopic analysis confirmed the diagnosis.

RESULTS

For this patient, clopidogrel (Plavix) therapy was the only risk factor related to SSEH.

CONCLUSIONS

In any patient under clopidogrel (Plavix): Sanofi-Synthelabo, Bristol-Myers Squibb/Sanofi Pharmaceuticals) therapy and with a typical clinical presentation, SSEH should be suspected and quickly diagnosed, regardless of hemostatic status or the absence of other major risk factors.

Clopidogrel-induced spontaneous spinal epidural hematoma

The hemorrhagic side effects associated with the use of clopidogrel are within the acceptable range and occur mainly at skin or gastrointestinal sites. We report a case of spontaneous spinal epidural hematoma (SSEH) in a 60-yr-old woman who was treated with clopidogrel for frequent transient ischemic attacks. To our knowledge, this is the second reported case of clopidogrel-induced SSEH. The patient's symptoms and past history of clopidogrel use suggested the diagnosis and made the procedure proceed quickly to operate SSEH 9 hr after the onset of paraplegia. The outcome was excellent. Therefore, with the popularity of antiplatelet prescription, physicians should keep in mind and urgently treat this unusual but critical side effect.

Back pain in the elderly

Back pain in the elderly is a complex chief complaint, because numerous life-threatening or disabling conditions may present with signs and symptoms similar to those of more benign disease processes. An understanding of the limitations of physical examination and history distinguishing dangerous from benign causes is essential to avoid misdiagnosis and patient morbidity or mortality. This article describes the presentation and evaluation of dangerous causes of back pain, including vascular catastrophes, spinal cord compression syndromes, and infectious diseases. Less emergent musculoskeletal injuries are discussed briefly.