抗凝固療法中の脊椎手術 : 頸椎硬膜外血腫の1例とそのピットフォール

抄録

  A good hemostastatic environment is indispensable in the spinal surgery even when administering a strict anticoagulant therapy. The restoration of coagulant function can be achieved by the discontinuation of the anticoagulant agents and the reversal of anticoagulant status by administering vitamin K and/or some coagulant factors. However, sudden restoration of the coagulation function may cause a thromboembolic event for those patients who need anticoagulant therapy. The perioperative management of such patients is therefore much more complicated.

  A 59-year-old man receiving warfarin as an anticoagulant medication because he suffered from infectious endocarditis, and had had a mitral and aortic valve replacement operation two years ago. A year later, he suffered a cerebral infarction despite his warfarin medication. This time, he had a cervical spinal epidural hematoma beginning with neck pain and left hemiparesis that developed into tetraparesis. The spinal surgery for hematoma removal and laminoplasty was done under anticoaguation reversal. A drainage tube was placed into the epidural space. The anticoagulation with continuous administration of heparin was started 12 hours postoperatively for functional maintenance of his mechanical cardiac valve. His tetraparesis was improving. The drainage tube was removed 48 hours postoperatively. However, spinal rebleeding was encountered three hours after the drain removal, and the patient developed tetraparesis again. An emergency operation was performed. An epidural drain was placed again, and it was removed 12 hours later when the drainage was completed and coagulation function was maintained. The heparinization was restarted six hours after drain removal. Rebleeding did not occur, and the anticoagulant therapy was transferred from heparin injection to warfarin medication. The rehabilitation of motor function was gradually progressed.

  Herein, we consider the safest, optimal perioperative management of spinal surgery for the patients taking anticoagulation therapy such as warfarin medication.