Sudden Back Pain and Neurological Symptoms: A Rare Spinal Emergency Linked to Antiplatelet Therapy

Antiplatelet medications are commonly prescribed to reduce the risk of blood clots in people with cardiovascular or cerebrovascular conditions. Examples include aspirin, clopidogrel and ticlopidine.
 

Although these medications are widely used, they can increase the tendency to bleed. A rare but potentially serious complication is a spontaneous spinal epidural haematoma, where blood collects in the epidural space around the spinal cord and can compress neurological structures.
 

A 2012 case report published in the Journal of Orthopaedic Surgery described two patients who developed spontaneous spinal epidural haematomas while receiving antiplatelet treatment. Both patients presented with severe back pain followed by neurological deterioration, and MRI was used to establish the diagnosis.
 

Dr Wang Lushun of Arete Orthopaedic Centre was the lead author of the research, together with Gabriel Liu, Sivashankar Subramaniam, Thomas Aloysius Kah Wai Wong and Naresh Kumar. At the time of publication, the authors were affiliated with the Department of Orthopaedics at National University Hospital in Singapore.
 

The two cases had different outcomes, highlighting the importance of recognising the condition promptly and considering urgent decompression when spinal cord or nerve compression is present.

What Is a Spinal Epidural Haematoma?

A spinal epidural haematoma occurs when blood accumulates in the epidural space, the area between the outer covering of the spinal cord and the bones forming the spinal canal.
 

As the collection of blood increases, it can compress:

• The spinal cord

• Nerve roots

• Other neurological structures
   

The resulting pressure can cause neurological symptoms that may progress rapidly.
 

A spontaneous spinal epidural haematoma occurs without an obvious traumatic cause or another immediately identifiable reason such as a vascular malformation, tumour or infection.
 

The condition is rare, but neurological deterioration can be significant when the spinal cord or nerve structures become compressed.

Why Can Antiplatelet Medication Be Relevant?

Antiplatelet medications reduce the ability of platelets to aggregate and form clots.
 

They are commonly prescribed to help prevent vascular events such as:

• Heart attacks

• Ischaemic strokes

• Other arterial clot-related complications
   

Examples include:

• Aspirin

• Clopidogrel

• Ticlopidine
   

Because these medicines affect platelet function, bleeding complications are a recognised consideration.
 

The research described two cases occurring in patients taking antiplatelet medication. However, because the study was a report of two cases, it cannot establish that antiplatelet treatment alone caused the haematomas or determine the overall risk of this complication among people taking these medicines.

What Did the Research Investigate?

The authors reported two cases of spontaneous spinal epidural haematoma associated with antiplatelet treatment.
 

The two patients were taking different antiplatelet regimens:

• One patient was taking aspirin and clopidogrel

• The other was taking ticlopidine
   

Both patients developed acute back pain followed by neurological deterioration.
 

MRI was used to identify the epidural haematoma in both cases.
 

The researchers highlighted the importance of maintaining a high level of clinical suspicion when patients receiving antiplatelet therapy present with severe back pain and rapidly developing neurological symptoms.

Case 1: Severe Back Pain Followed by Neurological Changes

The first patient was a 60-year-old man who presented after an acute onset of worsening back pain.
 

He also developed:

• Numbness affecting both anterior thighs

• Weakness in the left lower limb

• Urinary retention
   

He had no history of trauma or previous back pain.
 

At the time, he was taking aspirin for atrial fibrillation and had also been taking clopidogrel for six months.
 

The combination of severe back pain, neurological symptoms and bladder dysfunction raised concern for a compressive spinal problem.

How Was the First Patient Diagnosed?

MRI showed an epidural collection extending from approximately T10 to L2, located posterior to the spinal cord.
 

The imaging findings were consistent with a spinal epidural haematoma.
 

The patient subsequently underwent emergency decompression.

What Treatment Did the First Patient Receive?

The patient underwent:

• Multilevel decompressive laminectomies from T10 to L2

• Evacuation of the epidural haematoma

• Posterior spinal fusion over the same levels
   

The procedure was performed within 24 hours of symptom onset.
 

The timing was important because the spinal cord was being compressed by the haematoma.

What Was the Outcome for the First Patient?

The first patient experienced a substantial neurological recovery.
 

By the first postoperative day, he had:

• Full sensorimotor function in the lower limbs

• Resolution of urinary dysfunction after the catheter was removed

• Progressive return to mobility
   

He was ambulant by the fourth postoperative day.
 

At nine-month follow-up, he remained well without a neurological deficit. Histological examination of the evacuated haematoma did not identify vascular malformation, tumour or infection.

Case 2: A Different Neurological Outcome

The second patient was a 70-year-old woman who presented with severe lower back pain followed by:

• Paraesthesia in both lower limbs

• Paralysis

• Urinary retention
   

She had been taking ticlopidine for three years following a previous cerebrovascular accident.
 

On examination, she had complete loss of motor power in both lower limbs, a sensory level around L1 and loss of anal tone.
 

The case illustrates how rapidly neurological function can deteriorate when a spinal epidural haematoma compresses the spinal cord or associated neural structures.

How Was the Second Patient Treated?

MRI confirmed the presence of a spinal epidural haematoma.
 

The patient underwent unilateral hemilaminectomies approximately 40 hours after the onset of symptoms to decompress the affected area and evacuate the haematoma.
 

Unlike the first patient, however, she did not demonstrate neurological improvement following surgery.
 

This difference between the two cases was an important observation in the paper.

Why Might Timing Matter?

The research authors highlighted the potential importance of early spinal decompression when a spinal epidural haematoma produces neurological deterioration.
 

The two cases had different treatment timings:

The cases do not prove that the difference in outcome was caused solely by the timing of surgery. Many factors can influence neurological recovery.
 

However, the contrasting outcomes support the authors' concern that prolonged spinal cord compression may reduce the likelihood of neurological recovery.

What Symptoms Can a Spinal Epidural Haematoma Cause?

Symptoms can vary depending on the location and size of the haematoma and the structures being compressed.
 

Possible symptoms include:

Sudden Severe Back Pain

Severe back pain may be one of the earliest symptoms.
 

The pain can develop suddenly and may be accompanied by neurological changes.

Numbness or Tingling

Patients may develop altered sensation in:

• Legs

• Arms

• Trunk
   

depending on the level of the spinal cord affected.

Muscle Weakness

Weakness may develop in one or more limbs and can progress rapidly.

Paralysis

Severe compression can lead to substantial or complete loss of motor function.

Bladder or Bowel Problems

Urinary retention or other changes in bladder or bowel function can indicate significant neurological involvement.
 

These symptoms require urgent medical assessment.

Why Can the Condition Be Difficult to Recognise?

The initial symptom may simply be back pain.
 

Back pain is extremely common and can have many causes, including:

• Muscle strain

• Degenerative spinal conditions

• Disc problems

• Arthritis

• Nerve irritation
   

In the first case described in the research, the patient was initially treated elsewhere for a presumed back sprain before neurological symptoms prompted further investigation.
 

This demonstrates why sudden severe back pain accompanied by neurological changes should not automatically be attributed to a routine musculoskeletal problem.

When Should Sudden Back Pain Be Treated as an Emergency?

Back pain requires urgent medical assessment when it occurs together with neurological warning signs.
 

These include:

• New or worsening weakness

• Numbness affecting the limbs

• Difficulty walking

• Loss of sensation

• Urinary retention

• Loss of bladder or bowel control

• Rapid progression of symptoms

• Severe pain with neurological deterioration
   

The combination of severe back pain and rapidly developing neurological symptoms is particularly important in people taking medications that affect bleeding.

How Is a Spinal Epidural Haematoma Diagnosed?

Medical History

Doctors may ask about:

• When the pain started

• How quickly symptoms progressed

• Previous spinal conditions

• Recent trauma

• Medication use

• Antiplatelet or anticoagulant treatment
   

Medication history is particularly important because it may influence the differential diagnosis.

Neurological Examination

Doctors may assess:

• Muscle strength

• Sensation

• Reflexes

• Walking ability

• Bladder function

• Other neurological signs

MRI

MRI is the key imaging investigation for diagnosing spinal epidural haematoma.
 

It can show:

• The location of the blood collection

• Its extent

• The degree of spinal cord compression

• The spinal levels involved
   

Both patients in the reported study were diagnosed using MRI.

What Treatment May Be Required?

Treatment depends on the patient's symptoms, neurological status, location and severity of the haematoma.
 

When significant neurological compression is present, urgent surgical decompression may be considered.
 

Surgical treatment can involve:

• Laminectomy or hemilaminectomy

• Evacuation of the haematoma

• Decompression of the spinal cord or nerve structures
   

The specific procedure depends on the location and extent of compression.

Does Everyone Taking Antiplatelet Medication Need to Worry?

No.
 

Aspirin, clopidogrel and other antiplatelet medications are widely used because they provide important protection against certain cardiovascular and cerebrovascular events.
 

The research involved only two cases and cannot establish how frequently spinal epidural haematoma occurs in people receiving antiplatelet therapy.
 

Patients should not stop aspirin, clopidogrel, ticlopidine or another prescribed antiplatelet medication without medical advice, because doing so can increase the risk of the condition the medication was prescribed to prevent.
 

Instead, patients should be aware of unusual symptoms and seek urgent medical assessment when appropriate.

What Did the Researchers Conclude?

The authors emphasised that clinicians should maintain a high index of suspicion for spinal epidural haematoma when patients receiving antiplatelet therapy present with severe back pain and rapidly progressive neurological deterioration.
 

They also concluded that urgent spinal decompression and evacuation of the epidural haematoma may provide a more favourable neurological outcome.

Contributors to the Research

Dr Wang Lushun of Arete Orthopaedic Centre was the lead author of this research, together with Gabriel Liu, Sivashankar Subramaniam, Thomas Aloysius Kah Wai Wong and Naresh Kumar.
 

At the time of publication, the authors were affiliated with the Department of Orthopaedics at National University Hospital, Singapore. The paper was published in the Journal of Orthopaedic Surgery in 2012, Volume 20, Issue 3, pages 386–390.
 

The report contributed to the published literature highlighting the possibility of spontaneous spinal epidural haematoma in patients receiving antiplatelet treatment and the importance of rapid recognition when neurological symptoms develop.

What Can Patients Learn From This Research?

The two cases provide several important clinical lessons.

Severe sudden back pain can have causes beyond muscle strain

When severe back pain develops abruptly, particularly alongside neurological symptoms, further assessment may be necessary.

Neurological symptoms are important warning signs

Weakness, numbness, paralysis or bladder dysfunction should not be ignored.

Medication history matters

Patients should tell emergency and medical teams about all medications, including antiplatelet drugs.

MRI can identify the problem

MRI was used to diagnose both patients in the reported cases.

Rapid deterioration requires urgent assessment

The research highlights the potential importance of timely decompression when a haematoma is causing neurological compression.
 

A 2012 case report by Dr Wang Lushun and colleagues described two patients who developed spontaneous spinal epidural haematomas while receiving antiplatelet treatment. Both patients presented with severe back pain followed by neurological deterioration, and MRI confirmed the diagnosis.
 

The outcomes differed. One patient underwent multilevel decompression and spinal fusion within 24 hours and achieved complete neurological recovery. The second underwent decompression approximately 40 hours after symptom onset but did not experience neurological improvement.

Research Reference

Wang L, Liu G, Subramaniam S, Wong TA, Kumar N. Spontaneous spinal epidural haematoma after antiplatelet treatment: a report of two cases. Journal of Orthopaedic Surgery (Hong Kong). 2012 Dec;20(3):386-390. DOI: 10.1177/230949901202000326. PMID: 23255653.
 

This article is for general information only and should not replace medical advice from a qualified healthcare professional.