Spontaneous spinal haemorrhage due to oral anticoagulant Rx
Published in the European Journal of Case Reports in Internal Medicine, the authors describe the case of a 69-year-old patient who was admitted to the emergency department with a 6-hour history of epigastric pain without radiation and associated with acute cervical pain with lumbar radiation described as severe. The patient had previously been fitted with a mitral prosthetic valve and was being anticoagulated with warfarin.

The pain remained intense despite analgesia, including with morphine. The electrocardiogram and cardiac enzymes were normal. The echocardiogram was negative for valvular prosthetic dysfunction and for abnormalities of myocardial contraction.

Blood analysis revealed a leucocyte count of 12,200/μl (normal: 4,000–10,000/μl) with 88.5% neutrophils, a haemoglobin of 15.9 g/dl (normal: 13.6–18.0 g/dl) and a platelet count of 189,000/μl (normal: 1,400,000–440,000/μl). Prothrombin time was 41.0 seconds, INR was 3.2 and D-dimers were 225.0 ng/ml (normal: 0–500 ng/ml). Creatinine was 0.77 mg/dl (normal: <0.9 mg/dl) and C-reactive protein was negative.

A normal aortic angio-scan ruled out aortic disease. Four hours after admission, the patient experienced severe posterior thoracic pain without radiation and began to develop mild motor and sensory deficits in his lower extremities. Symptom severity rapidly progressed, and within 30 min the patient had paraparesis of the limbs (grade 2 in both legs), with bilateral sensory loss to the D1 dermatome level, with normal and symmetrical osteotendinous reflexes. The patient underwent an emergency medullar contrast CT scan which revealed a C5–D2 intracanalicular medullar haematoma.

At this point, the case was discussed with the neurosurgical team who decided on an emergency transfer to the reference centre for a decompression laminectomy. However, despite the prompt neurosurgical approach, the patient maintained paraparesis of the limbs after the procedure. After 2 months of physical rehabilitation with intensive physiotherapy, the patient achieved only minimal recovery, maintaining a high level of dependence in activities of daily living.

Learning Points:-
• This article reports an unusual presentation of spontaneous spinal haematoma, imposing the careful elaboration of differential diagnoses, which is very important in internal medicine.

• The lack of studies about the etiology and treatment of spontaneous spinal haematoma underlines the need for further studies and research in the area in order to increase the scientific evidence on the approach of these patients

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