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Canadian Journal of Anesthesia 50:750-751 (2003)
© Canadian Anesthesiologists' Society, 2003

Correspondence

Spontaneous spinal hemorrhage complicating anticoagulant therapy

Rachid Badaoui, MD, Michel Koukougnon, MD, Chafik El kettani, MD, Martial Ouendo, MD, Ramzi Rekik, MD and Jean Tchaoussoff, MD

Amiens, France

To the Editor:

We report a relatively rare but potentially devastating hemorrhagic consequence of anticoagulation therapy that can lead to spinal cord injury (SCI). The precise incidence of SCI from intraspinal hematoma is unknown, though it is clearly low.1–3 Spinal anesthesia is a risk factor for this complication.4

A 61-yr-old man was taking acenocoumarol 4 mg orally following an aortic valve replacement. The prothrombin time (PT) was maintained at 1.5 times the control value. Four years after the operation, he complained of severe neck pain, numbness and weakness of the legs and headache with sensory deficits and urinary retention. No trauma occurred in the days preceding his neurologic symptoms. Acenocoumarol therapy was discontinued, and 10 mg of vitamin K were administered intravenously. A C7–D4 subdural hematoma was revealed by magnetic resonance imaging (FigureGo). Anticoagulation was reversed immediately with 250 mL of fresh frozen plasma (FFP) and an emergency decompressive laminectomy performed to remove the D1–D3 subdural hematoma. Postoperative recovery was complete ten days later.



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  		FIGURE The C7–D4 subdural hematoma revealed by magnetic resonance imaging.

 
Unlike intracranial hemorrhage, which is usually subdural, intraspinal hemorrhage usually occurs in the epidural space. Intraspinal hematomas have been associated with the use of oral anticoagulant agents and heparin, antiplatelet therapy, trauma, straining, and lumbar puncture.2,3 Typically, the first complaint is of severe pain, often with a radicular component. Neurologic deficits follow intraspinal ruptures. Although they usually progress over several hours, they may develop in minutes or days and should be investigated immediately. There is no difference between spontaneous and anesthesia-related spinal hematomas.4

Suspicion of intraspinal bleeding establishes a crisis situation. The decisions made at the discovery of the first signs and symptoms will ultimately determine outcome. Anticoagulant and antiplatelet drugs should be discontinued. Reversal of anticoagulation is readily accomplished by administering commercially available prothrombin complex containing concentrates of factors II, VII, IX, and X. Alternatively, FFP may be used. Phytomenadione should be given at the time plasma or prothrombin complex is infused because they have a short duration of action. Recent studies have indicated that very large volumes of FFP are required to correct the PT in urgent situations.5

Prompt radiological assessment is mandatory. Confirmation of the hematoma may be made by magnetic resonance imaging, computed tomography scans or myelography.1 The presence of intraspinal bleeding dictates emergency decompressive laminectomy and evacuation of the hematoma to prevent or minimize permanent neurologic deficits caused by SCI. Spontaneous remission of an intraspinal hematoma has been reported only rarely.

References

1 Cakirer S, Basak M, Galip GM. Cervical hematomyelia secondary to oral anticoagulant therapy: case report. Neuroradiology 2001; 43: 1087–8.[Medline]

2 Morandi X, Riffaud L, Chabert E, Brassier G. Acute nontraumatic spinal subdural hematomas in three patients. Spine 2001; 26: 547–51.

3 Schenk JF, Morsdorf S, Pindur G, et al. Analysis and occurrence of adverse events with oral anticoagulant therapy. Semin Thromb Hemost 1999; 25: 65–71.

4 Wildforster U, Schregel W, Harders A. Delayed lumbar epidural hematoma. Discussion of the risk factors: hypertension, anticoagulation and spinal anesthesia (German). Anasthesiol Intensivmed Notfallmed Schmerzther 1998; 33: 517–20.[Medline]

5 Makris M, Greaves M, Phillip WS, Kitchen S, Rosendaal FR, Preston EF. Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thromb Haemost 1997; 77: 477–80.[Medline]





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