Acute spontaneous cervical epidural hematoma with neurological deficit after low-molecular-weight heparin therapy: role of conservative management

Abstract

Background Context Spontaneous spinal hematoma (SSH) after low-molecular-weight heparin (LMWH) therapy is a rare cause of compressive myelopathy with neurological deficit. Emergent surgical decompression is commonly advocated for optimal neurological recovery. Only three cases of spontaneous spinal subdural hematomas after LMWH therapy have been reported in the literature, and this is the first report of a spontaneous cervical epidural hematoma (EDH). Purpose To highlight the importance of conservative management in an unusual case of cervical EDH with neurological deficit after LMWH therapy. Study Design Clinical case report. Methods A 65-year-old man presented with weakness of upper and lower limbs with bowel and bladder dysfunction after LMWH therapy for an acute coronary syndrome. Magnetic resonance imaging (MRI) revealed an anterior cervical EDH extending from C4 to T1 with significant cord compression. Associated comorbidities precluded emergent surgical intervention, and the patient was managed conservatively with cessation of LMWH therapy. Results The patient showed signs of early neurological recovery within 24 hours (ASIA C [American Spinal Injury Association] to ASIA D) of cessation of LMWH, and hence surgery was deferred. Complete motor and sensory recovery was observed at 1-month follow up with resolution of the cervical EDH without any cord compression evident on the MRI. Conclusions LMWH therapy is an important cause of SSH leading to significant neurological deficits. Conservative management is a viable treatment option in patients who demonstrate early and sustained neurological recovery with the cessation of LMWH therapy.