(Kiosk 8) Pulmonary Embolism in a Patient with Spinal Cord Myelopathy After Temporary Hold of Prophylactic Anticoagulation: Case Report

Case Diagnosis: A 62-year-old male patient developed spinal cord myelopathy after spinal surgery, which led to a pulmonary embolism after temporary hold of venous thromboembolism (VTE) prophylaxis.

Case Description or Program Description: The patient had a pertinent history of tobacco abuse, recent humeral fracture, and recent glucocorticoid use. He underwent anterior cervical discectomy and fusion after being diagnosed with spinal stenosis. Perioperatively, VTE prophylaxis was held for 12 days based on surgeon’s recommendation. The patient was admitted to inpatient rehabilitation due to concerns for cervical myelopathy after surgery. Prophylactic VTE anticoagulation was initiated on admission to inpatient rehabilitation. The patient progressed through his rehabilitation hospitalization without notable extremity pain, swelling, or shortness of breath. It was planned to discharge the patient home within the next several days.

Setting: Acute Inpatient Rehabilitation Hospital

Assessment/Results: On day 8 of rehabilitation hospitalization, without any inciting factors, the patient suddenly developed significant dyspnea, hypotensive, and suffered a cardiac arrest. The patient was transported to the emergency room where workup including extensive lab tests, point of care ultrasound, and clinical evaluation led to the highly presumed diagnosis of a pulmonary embolism.

Discussion (relevance): Decision for perioperative VTE prophylaxis after spine surgery is often surgeon-dependent given the currently undefined consensus for a safe time to initiate after surgery. This patient’s prolonged perioperative immobilization, tobacco abuse, use of steroids (greater than 10 milligrams of prednisone equivalence), and recent long bone fracture are all known VTE risk factors. We postulate that it is valuable to complete a lower extremity doppler on inpatient rehabilitation patients whom have been without VTE prophylaxis for extended periods of time and have multiple risk factors for VTE.

Conclusions: Patients admitted to rehabilitation hospitals who have multiple risk factors for VTE and are without perioperative VTE prophylaxis for more than 1 week should be screened on admission with lower extremity dopplers to rule out VTE.