Anticoagulant induced spontaneous spinal epidural hematoma, conservative management or surgical intervention—A dilemma?

Spontaneous spinal epidural hematoma (SSEH) is a rare cause of cord compression. SSEH with neurological deficit is an emergency situation that is commonly considered an indication for emergency surgical decompression. We describe a patient with SSEH who recovered clinically and radiologically with conservative treatment. A 25-year-old hypertensive male presented with acute onset back pain followed by asymmetrical paraparesis. He had sensory level at D9 dermatome with preserved bladder and bowel functions. He was taking anticoagulants for deep venous thrombosis of the left lower limb. Surgery was deferred because of the deranged coagulation profile. He was managed conservatively with correction of coagulopathy. After 3 days, he recovered significantly. Repeat neuroimaging revealed significant resolution of epidural hematoma. The conservative approach can be considered for selected patients who are unsuitable for early surgical intervention, those with stable neurological status [American Spinal Injury Association (ASIA) Scale E], or those in whom early recovery of function has been initiated with ASIA Scale C or D. Neurological status at presentation and suitability for surgical intervention seem to be important determinants of the type of therapeutic intervention.