Spontaneous Spinal Subdural Hematoma Associated With Rivaroxaban and Aspirin Use: A Report of a Rare Case

A spontaneous spinal subdural hematoma (SSSH) is a rare but potentially deadly condition characterized by the presence of blood in the subdural space, commonly causing compression of the spinal cord and acute neurological deficits. Urgent surgical intervention with a decompressive laminectomy is warranted to avoid lasting deficits. The literature on this pathology is scarce, and the etiology is still poorly understood, although associations have been established with arteriovenous malformations, rupture of epidural vessels, and anticoagulant use, among others. This study presents the case of an 81-year-old Hispanic woman with a past medical history including an unspecified arrhythmia on treatment with oral anticoagulation who presented to the emergency room with sudden-onset, localized low back pain and an acute neurological deficit consisting of bilateral lower extremity paraplegia and areflexia. Magnetic resonance imaging (MRI) of the thoracic spine shows a 10-cm-long subdural hematoma causing compression from T5 to T10. At this time, the patient also developed an unstable atrial fibrillation with rapid ventricular response. After cardiac stabilization, a thoracic decompressive laminectomy with hematoma evacuation was performed. The degree of preoperative neural deficit and time to surgical intervention are prognostic factors for clinical recovery in these patients. Anticoagulant medication use is a risk factor for SSSH, and a high index of suspicion is needed for patients presenting with acute-onset back pain and neurological deficits, especially in the setting of known risk factors. MRI is the diagnostic tool of choice, and urgent surgical decompression is warranted to prevent further neurologic deterioration.