USE OF TOPICALLY APPLIED RT-PA IN THE EVACUATION OF EXTENSIVE ACUTE SPINAL SUBDURAL HAEMATOMAS

Abstract

Objective: Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. A minimally invasive technique of decompression, using topical recombinant tissue plasminogen activator (rt-PA), is presented in two patients with extensive spinal intradural haematoma.

Clinical Presentation: Two patients, receiving long-term anticoagulation therapy, presented with acute-onset back pain progressing to paraparesis. MRI of the spine demonstrated spinal subdural haematomas extending over fifteen vertebral levels in one and twelve in the other patient.

Intervention: An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with recombinant tissue plasminogen activator (rt-PA), followed by saline lavage. Post-operative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient.

Conclusion: Topical application of rt-PA for spinal sub-dural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimizing surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.