Abstract
Introduction
Spinal subdural hematomas are rare, disabling hemorrhages. Ankylosing spondylitis (AS) is a relatively common inflammatory condition of the spine that can progress to a fragile, unstable fusion vulnerable to fracture. While spinal epidural hematomas have been described, subdural hematomas to date have not been reported in AS. In this report, we describe the unique case of a patient on warfarin with AS who developed a spinal subdural hematoma and fracture in the absence of trauma. We then discuss the pathogenesis, presentation, prognosis, and management strategies for this unique diagnosis.
Case presentation
A 60-year-old man with recent AS diagnosis and atrial fibrillation on warfarin presented with 96 h of low back pain and 24 h of leg weakness and urinary retention. CT imaging revealed a bamboo spine and fracture of the posterior elements at L4, while MR revealed a hematoma with thecal sac compression. The warfarin was reversed and the patient taken to the operating room; on laminectomy, however, no hematoma was encountered. The patient then underwent intraoperative ultrasound, durotomy, and evacuation of a thick subdural hematoma, followed by posterior fusion.
Discussion
This case represents the first report of an AS patient who developed a subdural hematoma requiring evacuation. Although rare, the clinician should maintain a broad differential and be familiar with this unique pathology, particularly in high-risk patients, such as those with suspected fractures or on warfarin. In patients with back pain and myelopathic symptoms, rapid diagnosis followed by prompt evacuation allows for the best opportunity for neurologic recovery.
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References
Russell NA, Benoit BG. Spinal subdural hematoma. A review. Surg Neurol. 1983;20:133–7.
Aono H, Ohwada T, Hosono N, Tobimatsu H, Ariga K, Fuji T, et al. Incidence of postoperative symptomatic epidural hematoma in spinal decompression surgery. J Neurosurg Spine. 2011;15:202–5.
Edelson RN, Chernik NL, Posner JB. Spinal subdural hematomas complicating lumbar puncture: occurrence in thrombocytopenic patients. Arch Neurol. 1974;31:134–7.
Nagamoto Y, Takenaka S, Aono H. Postoperative spinal subdural lesions following lumbar spine surgery: prevalence and risk factors. Asian Spine J. 2017;11:793–803.
Kokubo Rinko, Kim Kyongsong, Mishina Masahiro, Isu Toyohiko, Kobayashi Shiro, Yoshida Daizo, et al. Prospective assessment of concomitant lumbar and chronic subdural hematoma: is migration from the intracranial space involved in their manifestation? J Neurosurg Spine. 2014;20:157–63.
Hung KS, Lui CC, Wang CH, Wang CJ, Howng SL. Traumatic spinal subdural hematoma with spontaneous resolution. Spine. 2002;27:E534–8.
Han PatrickP, Theodore Nicholas, Porter RandallW, Detwiler PaulW, Lawton MichaeLT, Robert, Spetzler F. Subdural hematoma from a Type I spinal arteriovenous malformation. J Neurosurg Spine. 1999;90:255–7.
Braun J, Sieper J. Ankylosing spondylitis. Lancet. 2007;369:1379–90.
Ghozlani I, Ghazi M, Nouijai A, Mounach A, Rezqi A, Achemlal L, et al. Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis. Bone. 2009;44:772–6.
Wu CT, Lee ST. Spinal epidural hematoma and ankylosing spondylitis: case report and review of the literature. J Trauma. 1998;44:558–61.
Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, et al. International standards for neurological classification of spinal cord injury (Revised 2011). J Spinal Cord Med. 2011;34:535–46.
Khan MA. Epidemiology of HLA-B27 and arthritis. Clin Rheumatol. 1996;15 Suppl 1:10–2..
Hacquard-Bouder C, Ittah M, Breban M. Animal models of HLA-B27-associated diseases: new outcomes. Joint Bone Spine. 2006;73:132–8.
Fox MarkW, Onofrio BurtonM, John, Kilgore E. Neurological complications of ankylosing spondylitis. J Neurosurg. 1993;78:871–8.
Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119–42.
Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg. 1995;83:1–7.
Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev. 2003;26:1–49.
Castillo JM, Afanador HF, Manjarrez E, Morales XA. Non-traumatic spontaneous spinal subdural hematoma in a patient with non-valvular atrial fibrillation during treatment with rivaroxaban. Am J Case Rep. 2015;16:377–81.
Sandvig A, Jonsson H. Spontaneous chronic epidural hematoma in the lumbar spine associated with Warfarin intake: a case report. SpringerPlus. 2016;5:1832.
de Beer MH, Eysink Smeets MM, Koppen H. Spontaneous spinal subdural hematoma. Neurologist. 2017;22:34–9.
Maste P, Paik S-H, Oh J-K, Kim Y-C, Park M-S, Kim T-H, et al. Acute spinal subdural hematoma after vigorous back massage: a case report and review of literature. Spine. 2014;39:E1545–8.
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Esfahani, D.R., Shah, H.P., Behbahani, M. et al. Spinal subdural hematoma and ankylosing spondylitis: case report and review of literature. Spinal Cord Ser Cases 4, 30 (2018). https://doi.org/10.1038/s41394-018-0064-9
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DOI: https://doi.org/10.1038/s41394-018-0064-9
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