Rivaroxaban‐induced Epidural Hematoma and Cauda Equina Syndrome after Total Knee Arthroplasty: a Case Report

Abstract

Deep venous thrombosis and pulmonary embolism are a major cause of morbidity and mortality after arthroplasty. Chemoprophylaxis has been effective in reducing the incidence of symptomatic deep venous thrombosis, but not of pulmonary embolism, after total hip arthroplasty (THA) and total knee arthroplasty (TKA)1. Rivaroxaban, an orally administered factor Xa inhibitor, has recently been introduced for reducing the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after hip and knee arthroplasty2, 3, 4, 5. Factor Xa catalyzes the conversion of prothrombin to thrombin. Because a single molecule of Xa can generate thousands of thrombin molecules, factor Xa is an excellent drug target6. In many ways, rivaroxaban is an ideal drug, being orally administered, usually requiring no monitoring and having a faster onset of action than warfarin. However, like other effective thromboprophylactic agents, rivaroxaban has been associated with an increased incidence of bleeding from surgical wounds or other sites. Here we present a case of a patient who developed a symptomatic epidural hematoma after postoperative administration of rivaroxaban. The patient was informed that we wanted to submit this case for publication and gave written permission. The purpose of this report was to describe an unanticipated, early complication of a new type of DVT chemoprophylaxis after total knee arthroplasty, thus educating patients and surgeons about the possible risks of chemoprophylaxis. This patient appeared to develop the complication while bridging from a different anticoagulant to rivaroxaban. We now recommend extreme caution re‐using rivaroxaban in the setting of recent spinal anesthesia after arthroplasty.