Epidural Hematoma and Intraoperative Hemorrhage in a Spine Trauma Patient on Pradaxa (Dabigatran)

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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 should aware of this medication's place for 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 approved by the Food and Drug Administration to decrease stroke risk in patients with atrial fibrillation. Unlike warfarin, dabigatran does not require international normalized ratio monitoring. On the contrary, 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.The patient presented with burst fractures at the T7 and T12 levels. Cord compression was noted at both levels, and was worse at T12. Canal stenosis resulted from both 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 used a number of recommended “reversal” agents with little effect on the severe intraoperative hemorrhage. Failure to control the bleeding required interruption of the procedure after the canal decompression. The patient was taken back to the operating room 7 days later for an instrumented posterior spinal fusion.Conclusion.As dabigatran (Pradaxa) has recently been approved by the Food and Drug Administration, 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 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.

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