Spontaneous epidural haematoma presenting as cord compression in a patient receiving clopidogrel

Sir, Spinal cord compression secondary to spontaneous epidural haematoma from the use of anticoagulant and anti-platelet therapies has rarely been reported (Van Schaeybroeck et al., 1998; Pullarkat et al., 2000; Kirazli et al., 2004). We present a case of thoracic cord compression from spontaneous epidural haematoma in a patient receiving clopidogrel. Our patient, a 62-year-oldChinesemale, presented with acute weakness and numbness of both lower limbs whilst straining during defaecation. His medical history was significant for hypertension and ischaemic heart disease, for which he was taking clopidogrel 75 mg/day. Clinical examination showed flaccid paraparesis of both lower limbs with up-going plantar responses, motor power of Medical ResearchCouncil (MRC) grade 0/5 in both lower limbs, sensory loss to pinprick up to the T6 dermatome and lax anal tone. Proprioceptive and vibratory sensation were likewise absent in both lower limbs. Intravenous dexamethasone was commenced. There was no thrombocytopaenia or coagulopathy. An magnetic resonance imaging (MRI) of the spine was performed, revealing an epidural haematoma extending from the C6 to T10 levels (Fig. 1), most severe at the level of the fifth thoracic vertebra (Fig. 2). No arteriovenous malformation (AVM) was detected on arteriogram and venogram or at the extensive emergency decompression laminectomy in the first to tenth thoracic vertebral levels. Partial recovery was achieved by the next day, with a sensory level to T10 and partial recovery of strength in the lower limbs. In a review of 613 patients with spinal haematoma, it was estimated that in up to a third of the cases, no aetiological factor can be identified for the cause of the bleeding (Kreppel et al., 2003). Epidural venous plexi have been suggested as the source of haemorrhage, as epidural veins are more susceptible to rupture after activities that transiently raise venous pressure such as mild exercise, coughing, straining, or other vasalva manoeuvres (Adamson et al., 2004). Clopidogrel therapy alone probably did not trigger epidural haematoma and it is likely that an additional locus minoris resistentiae and increased pressure in the epidural venous plexi resulted in the epidural haematoma.