1209 - Acute Cauda Equina Syndrome Secondary to a Spinal Epidural Hematoma: A Case Report

Case Diagnosis: Acute cauda equina syndrome secondary to spinal epidural hematoma formation following lumbar laminectomy and resumption of therapeutic anticoagulation

Case Description: An 80-year-old male with history of pulmonary embolism on warfarin, stroke, dementia, cognitive impairment, and lumbar stenosis presented to acute rehabilitation following elective L2-L4 laminectomy. Warfarin was resumed two weeks postoperatively per neurosurgery recommendations. Four days after restarting anticoagulation, patient was noted to have difficulty ambulating in therapy. He had been ambulating with contact-guard assist but now required maximum assist, demonstrating functional decline. Patient reported postoperative pain but did not self-report neurological changes. Exam was notable for decreased proximal and absent distal lower extremity strength, compared with full strength on admission. Cord Compression MRI demonstrated an epidural hematoma in the laminectomy defect, causing cauda equina compression at L1-L3. Patient underwent L1 laminectomy for hematoma evacuation. He was readmitted to acute rehabilitation with minimal improvement in motor strength but progressed from being lift-dependent for transfers to using the slideboard with assist. Wheelchair mobility also improved from requiring maximum assist to supervision.

Discussions: Spinal epidural hematoma can be a complication that occurs following spinal surgery. Preoperative coagulopathy is a known risk factor. Symptoms can include acute-onset back pain or radicular pain, motor or sensory deficits, and bladder or bowel incontinence. Management consists of urgent surgical exploration and decompression. Neurological deficits typically improve but can persist.

Conclusions: Spinal epidural hematoma should be suspected in patients with new neurological deficits who have recently undergone spinal surgery and are reinitiated on therapeutic anticoagulation. Preexisting cognitive deficits can preclude some patients from self-reporting new symptoms. In these patients, it is important to perform serial neurologic examinations. Therapy teams are also instrumental in identifying new deficits, which subsequently allows for timely diagnosis and intervention. Following intervention, acute inpatient rehabilitation should be encouraged in order to maximize patients’ function and independence.