Spontaneous cervicothoracic spinal epidural hematoma following physiotherapy in an elderly patient on apixaban

Abstract

Background:

Spontaneous spinal epidural hematomas (SSEHs) are rarely reported in patients on direct oral anticoagulants (DOACs), such as apixaban. Here, we report an 87 years old who developed a SSEH following cervical physical therapy.

Case Description:

An 87-year-old male on apixaban presented with acute neck pain and rapidly progressive quadriparesis following manual cervical physiotherapy. The magnetic resonance imaging revealed an extensive dorsal epidural hematoma extending from C1 to T8, causing severe cord compression. After anticoagulation reversal, urgent multilevel partial hemilaminectomy and hematoma evacuation were performed. The patient fully recovered neurological function 1 year later.

Conclusion:

Extensive cervicothoracic SSEH may occur in patients on DOAC following cervical physical therapy.

INTRODUCTION

Spontaneous spinal epidural hematomas (SSEHs) arise in approximately 0.1/100,000 individuals/year.[1,3] They most commonly occur in older adults, especially those on anticoagulation, those with vascular malformations, with coagulopathies, and/or other conditions associated with sudden increases in venous pressure.[1,3] Early surgical treatment, particularly within 12–24 h of symptom onset, has been associated with improved outcomes.[6,10] Here, an 87-year-old male acutely on a direct oral anticoagulant (DOAC) (apixaban) developed a magnetic resonance (MR)-documented cervicothoracic SSEH (C1–T8) following cervical physiotherapy; after immediate reversal of the apixaban, surgical excision resulted in a full neurological recovery 1 year later.

CASE PRESENTATION

An 87-year-old male who had undergone manual cervical physical therapy earlier that day presented with the sudden onset of posterior neck pain and progressive quadriparesis. Due to his prior history of deep vein thrombosis, he was chronically on the anticoagulant apixaban (5 mg twice daily). Neurologically, the patient was tetraplegic with preserved superficial/deep sensation and intact sphincter function. The emergency computed tomography excluded any osseous injury, while the appropriate study, the MR imaging (MRI), demonstrated a large dorsal cord-compressive C1-T8 epidural hematoma (i.e., most compressive at C2/3 and T4/5, and predominantly right-sided in the cervical region and left-sided below T4) [Figures 1 and 2]. Within 6 h of presentation, and after reversal of the apixaban (i.e., using 3500 IU of prothrombin complex/2 g of tranexamic acid), the patient underwent urgent multilevel partial hemilaminectomies (C3– T3) for complete hematoma evacuation. Intraoperatively, there was fresh venous bleeding without an identifiable source. The postoperative MRI confirmed complete hematoma evacuation with adequate decompression of the spinal cord [Figure 3]. Postoperatively, the patient immediately began to improve but did not fully neurologically recover until 1 year later. Notably, anticoagulation with apixaban was restarted at a reduced dose (2.5 mg twice daily) after 3 weeks, and he remains under close hematological supervision.

Figure 1:

Preoperative sagittal T1-weighted contrast-enhanced magnetic resonance imaging demonstrating an extensive dorsal, cervicothoracic epidural hematoma extending from the upper cervical to the mid-thoracic levels, causing significant spinal cord compression.

Figure 2:

Axial T2-weighted magnetic resonance imaging at the T4–T5 level demonstrating a dorsal epidural hematoma causing severe spinal cord compression with ventral displacement of the spinal cord.

Figure 3:

Postoperative sagittal T2-weighted magnetic resonance imaging demonstrating complete evacuation of the epidural hematoma and adequate decompression of the spinal cord.

DISCUSSION

SSEHs are rarely attributed to anticoagulation, particularly among older adults.[3,5,7] The pathophysiology is likely attributed to bleeding from the epidural venous plexus occurring in the setting of altered coagulation or increased venous pressure.[1] Here, the SSEH arose due to cervical physiotherapy/manipulation; similar adverse events have been reported in other case studies for patients on different types of anticoagulation.[2,3,5,9]

MR studies, the “gold standard” for diagnosing SSEH, should be immediately followed by STAT/prompt decompressive surgery.[1,3,4,6,7] In our case, urgent decompression resulted in rapid neurological improvement, with normal function being noted at 1 postoperative year.

Several studies from the literature demonstrate that DOAC-associated SSEH cases [Table 1] who were typically elderly and anticoagulated favorably recovered following early surgery [Table 1].

Table 1:

Selected spontaneous spinal epidural hematomas cases associated with anticoagulation or cervical manipulation.

CONCLUSION

Extensive cervicothoracic SSEH may occur in patients on DOAC following cervical physical therapy/cervical manipulation.

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that they have used artificial intelligence (AI)-assisted technology for minor language editing assistance. No AI tools were used for data analysis, interpretation, or figure preparation.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.