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Epidural Hematoma & Intra-operative Hemorrhage in a Spine Trauma Patient on Pradaxa(R) [Dabigatran].
AB Study Design. The authors present a case report of a 72-year-old man who presented with back pain and lower extremity weakness after a fall from his roof. Objective. Use of Dabigatran [Pradaxa], a new oral anticoagulant, is rapidly increasing. Spine specialists must be aware of this medication's places on the management of patients with spine pathology. In particular, we intend to report on the emergent treatment of a patient with spinal trauma and epidural hematoma with cord compression. Summary of Background Data. Dabigatran [Pradaxa] is FDA approved to decrease stroke risk in patients with atrial fibrillation. Unlike Warfarin, Dabigatran does not require international normalized ratio (INR) monitoring. On the other hand, it is difficult to reverse in patients requiring emergent surgical intervention. Methods. This is a retrospective review of a patient treated at our institution. Results. Our patient presented with burst fractures at the T7 and T12 levels. Cord compression was noted at both levels, worst at T12. Canal stenosis resulted both from retropulsed bone and epidural hematoma. The patient exhibited bilateral lower extremity numbness and weakness, ASIA C. The patient was taken urgently to the operating room for cord decompression and planned operative stabilization. The treating team employed a number of the recommended "reversal" agents with little effect on the severe intraoperative hemorrhage. Failure to control this bleeding required interruption of the procedure after the canal decompression. The patient was taken back to the operating room seven days later for an instrumented posterior spinal fusion. Conclusion. As Dabigatran [Pradaxa] has recently been FDA approved, many spine specialists are not familiar with this agent. Many of the reversal agents (e.g. Vitamin K and Protamine) useful for other classes of anticoagulants, have no impact on Pradaxa. Similarly, Prothrombin Time and Partial Thromboplastin Times (PT & PTT) have limited utility in estimating the patient's true clotting status. The purpose of this case report is to alert spine specialists to this drug and its implications on spine care. The drug's pharmacokinetics, clinical assessment of clotting status, and reversal options are discussed. (C) 2012 Lippincott Williams & Wilkins, Inc.
AB Study Design. The authors present a case report of a 72-year-old man who presented with back pain and lower extremity weakness after a fall from his roof. Objective. Use of Dabigatran [Pradaxa], a new oral anticoagulant, is rapidly increasing. Spine specialists must be aware of this medication's places on the management of patients with spine pathology. In particular, we intend to report on the emergent treatment of a patient with spinal trauma and epidural hematoma with cord compression. Summary of Background Data. Dabigatran [Pradaxa] is FDA approved to decrease stroke risk in patients with atrial fibrillation. Unlike Warfarin, Dabigatran does not require international normalized ratio (INR) monitoring. On the other hand, it is difficult to reverse in patients requiring emergent surgical intervention. Methods. This is a retrospective review of a patient treated at our institution. Results. Our patient presented with burst fractures at the T7 and T12 levels. Cord compression was noted at both levels, worst at T12. Canal stenosis resulted both from retropulsed bone and epidural hematoma. The patient exhibited bilateral lower extremity numbness and weakness, ASIA C. The patient was taken urgently to the operating room for cord decompression and planned operative stabilization. The treating team employed a number of the recommended "reversal" agents with little effect on the severe intraoperative hemorrhage. Failure to control this bleeding required interruption of the procedure after the canal decompression. The patient was taken back to the operating room seven days later for an instrumented posterior spinal fusion. Conclusion. As Dabigatran [Pradaxa] has recently been FDA approved, many spine specialists are not familiar with this agent. Many of the reversal agents (e.g. Vitamin K and Protamine) useful for other classes of anticoagulants, have no impact on Pradaxa. Similarly, Prothrombin Time and Partial Thromboplastin Times (PT & PTT) have limited utility in estimating the patient's true clotting status. The purpose of this case report is to alert spine specialists to this drug and its implications on spine care. The drug's pharmacokinetics, clinical assessment of clotting status, and reversal options are discussed. (C) 2012 Lippincott Williams & Wilkins, Inc.
