Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: a case report

Abstract

Background Spinal epidural hematoma is a rare condition usually secondary to trauma and coagulopathy. To the best of our knowledge, we present the first case of a patient with an iatrogenic hypercoaguable state performing self-neck manipulation, which resulted in a spinal epidural hematoma and subsequent quadriparesis. Case presentation A 63-year-old man presented to the emergency department with worsening interscapular pain radiating to his neck 1 day after performing self-manipulation of his cervical spine. He was found to be coagulopathic upon admission, secondary to chronic warfarin therapy for the management of atrial fibrillation. Approximately 48 h after the manipulation, the patient became acutely quadriparetic and hypotensive. Urgent magnetic resonance imaging revealed a multilevel spinal epidural hematoma from the lower cervical to thoracic spine. Conclusions Partial C7, complete T1 and T2, and partial T3 bilateral laminectomy was performed for evacuation of the spinal epidural hematoma. Following a 2-week course of acute inpatient rehabilitation, the patient returned to his baseline functional status. This case highlights the risks of self-manipulation of the neck and potentially other activities that significantly stretch or apply torque to the cervical spine. It also presents a clinical scenario in which practitioners of spinal manipulation therapy should be aware of patients undergoing anticoagulation therapy.

Stroke-like manifestation of a spontaneous spinal epidural hematoma with spontaneous resolution: a case report

“…Causes which rapidly increase the intra-abdominal and thoracic pressure, such as pregnancy, coughing, sneezing, vomiting and urinating, may cause venous epidural plexus lesions [ 9 ]. When it comes to minor trauma, it may arise from significant dynamic stress, such as stretching exercises, injuries during physical activities, sports, daily routine activities, chiropractic spinal manipulation therapy or acupuncture [ 10 – 12 ]. There is also association of SEH with rheumatological conditions such as ankylosing spondylitis, but usually in a traumatic setting [ 13 , 14 ].…”

Stroke-like manifestation of a spontaneous spinal epidural hematoma with spontaneous resolution: A case report

“…Causes which rapidly increase the intra-abdominal and thoracic pressure, such as pregnancy, coughing, sneezing, vomiting and urinating, may cause venous epidural plexus lesions 9 . When it comes to minor trauma, it may arise from signi cant dynamic stress, such as stretching exercises, injuries during physical activities, sports, daily routine activities, chiropractic spinal manipulation therapy or acupuncture 10,11,12 . There is also association of SEH with rheumatological conditions such as ankylosing spondylitis, but usually in a traumatic setting 13,14 .…”

Spinal epidural hematoma after spinal manipulation therapy: Report of three cases and a literature review

“…We review 18 literature reports (Table 1 ). Three patients had a history of anticoagulant therapy, two had osteoporosis or spinal degeneration[ 9 - 11 ] , and three had a history of spinal degeneration[ 6 , 12 , 13 ]. There was also one case with an arteriovenous malformation[ 14 ].…”

“…SEH has been characterized as “idiopathic, spontaneous, and secondary”[ 16 , 17 ]. Most patients develop limb numbness and weakness, severe back pain, and quadriplegia or dyspepsia soon after SMT (up to a few hours later; Table 1 ), but there have also been reports of delayed symptoms (after 1-3 d[ 11 , 18 ]). All of our cases developed symptoms immediately after SMT, but one case was only detected by examination 3 d later.…”