Case Presentation:

We report the case of a 69-year-old Honduran male with a long history of non-valvular atrial fibrillation with a CHA2DS2-VASc Score= 2 (Age > 65 and Hypertension) anticoagulated with Rivaroxaban 20 mg po daily since 2013.  He presented with sudden onset of excruciating upper and lower back pain while seated at his cardiologist’s office after routine EKG.  This pain was immediately followed by bilateral lower extremity paresis rapidly progressing to paraplegia with bowel and bladder dysfunction over 15 minutes.  On exam, he had 5/5 upper extremity strength bilaterally, 0/5 strength with areflexia in the lower extremities, no clonus, negative Babinski, and no sensation to light touch, pinprick, or proprioception.  MRI in Honduras showed an acute spinal subdural hematoma from T3 inferiorly to the conus medullaris. He was brought to Miami by family. MRI here showed slight progression. Initial labs here were normal except for a slightly elevated prothrombin time, mild thrombocytopenia, and labs consistent with SIADH. On hospital day 2, he underwent attempted cervical and lumbar drainage insertion by neurosurgery.  Lumbar drain was unsuccessful, and cervical drain resulted in bloody CSF. The patient was discharged to rehabilitation on hospital day 29, then home to Honduras 6 weeks after presentation here without any recovery in neurologic function.

Discussion:

To our knowledge, no cases have reported an association of spontaneous spinal subdural hematoma (SSSH) with Rivaroxaban or any novel oral anticoagulant (NOAC). SSSH is a rare but disabling condition, accounting for only 4.1% of all intra-spinal hematomas.  Risk factors include arteriovenous malformations, coagulopathy, therapeutic anticoagulation, underlying neoplasms, or following a spinal puncture (iatrogenic). Prior reports associate SSSH with older anticoagulants. NOACs have been marketed as being safer than dose-adjusted Warfarin. This is important because hospitalists must have an index of suspicion of an atypical presentation of hemorrhage with anticoagulant use. The most common presenting symptom of SSSH is progressive motor weakness.  Almost half of all patients will experience spinal or radicular pain, described as an intense, knife-like pain at the site of the hematoma.   Our patient had a classical presentation. Unfortunately, it was not recognized early due to lack of clinical suspicion. Treatment is most frequently surgical evacuation.  For rapid neurological deterioration, early surgical management is essential.   Neurologic outcomes were found to be poor in 58% of patients who had late surgical intervention.

Conclusions: Non-traumatic spontaneous spinal subdural hematoma is a rare neurological emergency that may occur during the use of Rivaroxaban in patients with non-valvular atrial fibrillation.  Hospitalists should suspect SSSH in patients on Rivaroxaban with acute onset of severe back pain and neurologic symptoms to improve the odds of a favorable outcome.