01Approach to the Critical Patient/attcp44

Immediate stabilization

›Time-critical recognition

›Sudden severe back or neck pain with evolving neurological deficit — spinal surgical emergency

›Onset-to-deficit interval <1 hour — highest urgency, emergent MRI and neurosurgical activation

›Symptom-to-surgery interval is the key determinant of functional outcome

›Airway and breathing

›Cervical or high thoracic lesion at or above C4 — diaphragmatic paralysis risk

›Immediate airway assessment

›Prepare for emergent intubation if respiratory compromise

›SpO2 target >94%

›Supplemental oxygen for hypoxia

›If unable to protect airway, rapid sequence intubation

›Circulation

›Neurogenic shock pattern — hypotension with bradycardia in cervical or high thoracic (at or above T6) lesions

›SBP target >90 mmHg

›MAP target >85 mmHg for cord perfusion

›Vasopressor initiation for neurogenic shock unresponsive to fluids

›Norepinephrine first-line for neurogenic shock

›Atropine for symptomatic bradycardia

Key decision points

›Emergent MRI spine

›Order immediately on clinical suspicion — do not wait for laboratory results

›MRI is the imaging modality of choice (ACR Appropriateness Criteria — Usually Appropriate)

›CT spine as bridge if MRI unavailable or contraindicated

›Anticoagulation reversal

›Identify agent and last dose before reversal — critical for strategy

›Initiate reversal simultaneously with imaging workup — do not wait for surgical plan

›Thrombolytics absolutely contraindicated — can worsen hemorrhage and cause death

02History/hx64

Presenting symptoms

›Pain characteristics

›Sudden severe neck or back pain — chief complaint in ~79% of cases

›Often described as thunderclap or worst-ever pain

›Cervical, thoracic, or lumbar location depending on hematoma level

›Radicular pain

›Dermatomal distribution

›May precede or accompany weakness

›Neurological progression

›Motor weakness evolving minutes to hours after pain onset

›Bilateral lower extremity weakness (paraparesis or paraplegia) — thoracolumbar lesions

›All four extremity weakness (tetraparesis) — cervical lesions

›Sensory changes

›Numbness and tingling below level of lesion

›Saddle anesthesia — cauda equina involvement

›Sphincter dysfunction

›Urinary retention or incontinence

›Fecal incontinence — poor prognostic marker

›Exact time of symptom onset — critical for surgical decision-making

Alarm features

›High-urgency presentations

›Rapidly progressive paraparesis or tetraparesis — surgical emergency

›Complete motor deficit (ASIA Grade A) — strongest predictor of poor outcome

›Sphincter dysfunction — associated with poor prognosis

›Rapid deterioration <1 hour from onset to severe deficit

›Cervical hematoma with respiratory compromise — diaphragmatic paralysis risk

›Brown-Sequard syndrome — recognized presentation of cervical epidural hematoma

03Physical Exam/exam50

Neurological examination

›Motor assessment

›ASIA impairment scale grading — mandatory for all patients

›Grade A: complete — no sensory or motor function below level

›Grade B: sensory incomplete

›Grade C: motor incomplete — most key muscles grade <3

›Grade D: motor incomplete — most key muscles grade >/=3

›Grade E: normal

›Bilateral lower extremity strength testing — thoracolumbar lesions

›All four extremity strength testing — cervical lesions

›Grip strength and upper extremity testing — C4-T1 levels

›Sensory assessment

›Dermatomal sensory level — pinprick and light touch bilaterally

›Saddle anesthesia — perianal sensation testing

›Proprioception and vibration — posterior column integrity

›Reflexes

›Deep tendon reflexes below level — hyperreflexia upper motor neuron

›Hyporeflexia or areflexia in acute spinal shock phase

›Babinski sign — corticospinal tract involvement

›Rectal examination

›Perianal sensation

›Anal tone

›Voluntary anal contraction — critical for ASIA complete vs. incomplete classification

Vital signs assessment

›Hemodynamic pattern recognition

›Neurogenic shock — hypotension with paradoxical bradycardia

›Cervical or high thoracic lesions at or above T6

›Loss of sympathetic outflow below lesion level

04Differential Diagnosis/ddx46

Compressive myelopathy

›Spinal epidural hematoma — ICD-10 G97.31, S14.0XXA

›Most common form — epidural space blood accumulation

›Posterior epidural space most frequent location

›Spinal subdural hematoma — ICD-10 G97.31

›Crescentic shape on MRI differentiates from epidural

›May require intradural surgical approach

›Spinal subarachnoid hemorrhage

›Blood in subarachnoid space

›Often associated with vascular malformation or trauma

›Intramedullary hematoma (hematomyelia)

›Within cord parenchyma

›Often associated with cavernous malformation or trauma

Infectious and inflammatory causes

›Spinal epidural abscess — ICD-10 G06.1

›Fever, elevated WBC, ESR, CRP

›IV drug use, immunosuppression, recent spinal procedure

›Ring enhancement on MRI with gadolinium

›Distinguishing feature: fever absent in hematoma

›Transverse myelitis — ICD-10 G37.3

›Subacute onset over days to weeks

›Intramedullary T2 signal without mass

›No compressive lesion on imaging

Vascular causes

›Spinal cord infarction — ICD-10 G95.1

›Apoplectic onset similar to hematoma

›Anterior cord syndrome pattern

›No mass on MRI — T2 signal change without compressive lesion

05Laboratory Tests/lt41

Coagulation workup

›Prothrombin time and INR

›Warfarin effect quantification

›Baseline before reversal

›Target INR <1.5 for neurosurgical intervention

›Activated partial thromboplastin time

›Heparin effect monitoring

›Lupus anticoagulant screening

›Anti-Xa level

›LMWH activity quantification

›Some DOAC level estimation

Complete blood work

›Complete blood count

›Platelet count — target >100,000/microL for neurosurgical intervention

›Hemoglobin for transfusion planning

›WBC elevation suggests infectious etiology (epidural abscess)

›Comprehensive metabolic panel

›Renal function — creatinine and eGFR affect DOAC clearance

›Liver function — coagulation factor synthesis

›Electrolytes including sodium baseline

›Blood type and screen

›Anticipate possible surgical blood loss

›Crossmatch for high-risk lesions

Specialized coagulation testing

›DOAC-specific levels

›Dabigatran — ecarin clotting time or dilute thrombin time

›Rivaroxaban and apixaban — anti-Xa calibrated to specific agent

›Timing relative to last dose critical for interpretation

06Diagnostic Tests/dt82

Scoring Systems

›ASIA Impairment Scale

›Grade A: complete injury — no sensory or motor function preserved in sacral segments S4–S5

›Grade B: sensory incomplete — sensory but not motor function preserved below level

›Grade C: motor incomplete — motor function preserved, most key muscles below level grade <3

›Grade D: motor incomplete — motor function preserved, most key muscles below level grade >/=3

›Grade E: normal — sensory and motor function normal

›ASIA Grade A at presentation — strongest predictor of poor outcome regardless of surgical timing

›Frankel Classification

›Historical grading system still referenced in surgical literature

›Frankel D–E — favors conservative management trial

›Frankel A–C — surgical candidates with neurological deficit

›Surgical timing decision

›Surgery within 12 hours of neurological deficit onset — best functional outcomes

›Ultraearly surgery <12 hours — 100% favorable outcomes in one series

›Delayed surgery >12 hours — 63.6% favorable outcomes in same series

›Interval from neurological deficit onset to surgery is the key interval — not from pain onset

MRI

›MRI spine — modality of choice

›ACR Appropriateness Criteria: Usually Appropriate for acute myelopathy

›No ionizing radiation

›Superior soft tissue contrast for cord and hematoma characterization

›MRI sequences

›T1-weighted

›Acute hematoma (0–3 days) — isointense to hypointense on T1

›Subacute hematoma (3–14 days) — hyperintense on T1 due to methemoglobin

›T2-weighted

›Acute hematoma — hypointense rim with hyperintense center

›Cord edema — T2 hyperintensity within cord parenchyma

›Flow voids — suggest underlying vascular malformation

›STIR sequences

›Sensitive for cord edema and paraspinal soft tissue changes

›Gadolinium-enhanced T1

›Ring enhancement favors abscess over hematoma

›Vascular malformation characterization

›Not required for initial diagnosis

›Diffusion-weighted imaging

›Cord infarction shows restricted diffusion — helps differentiate from hematoma

›Hematoma localization on MRI

›Epidural — convex lenticular shape, biconvex or crescent, does not cross midline

›Posterior epidural most common — dorsal to cord

›Displaces dura ventrally

›Subdural — crescentic shape, crosses midline, displaces cord

›More diffuse spread than epidural

›Intramedullary — within cord parenchyma, fusiform cord expansion

›Extent of assessment

›Image entire spine if clinically uncertain — hematomas may be multisegmental

›Cervical, thoracic, and lumbar sequences as indicated

CT

›CT spine — secondary role in spinal hematoma

›Indications

›MRI unavailable or contraindicated (pacemaker, cochlear implant)

›Rapid assessment for bony pathology

›Post-traumatic evaluation for fracture

›Limitations

›Poor soft tissue contrast for cord and hematoma differentiation

›Hematoma may be isodense to surrounding structures acutely

›Cannot reliably distinguish hematoma from disc herniation

›CT myelography

›MRI contraindicated and CT insufficient

›Intrathecal contrast injection

›Demonstrates compressive lesion and extent

›Invasive — risk of neurological deterioration with positioning

›CT angiography

›Vascular malformation screening when DSA not immediately available

›Spinal AVM or dural AVF assessment

›Sensitivity inferior to DSA for small fistulas

Ultrasound

›Limited primary role in spinal hematoma diagnosis

›No direct visualization of spinal cord through intact spine

›Cannot replace MRI for definitive diagnosis

›Intraoperative ultrasound

›Real-time decompression assessment during laminectomy

›Confirms hematoma evacuation

›Guides extent of surgical exposure

›Point-of-care ultrasound adjunct role

›Bladder scan — urinary retention assessment

›Bladder volume >400 mL indicates acute retention — catheterize

›Cardiac evaluation in neurogenic shock

›Hypovolemia vs. distributive physiology

›IVC collapsibility for volume status

›Digital subtraction angiography

›Gold standard for vascular malformation detection

›Arteriovenous fistulas found in ~15% of cases on DSA

›Indicated after hematoma evacuation if no anticoagulant cause identified

›Performed after stabilization — not in acute emergency phase

07Disposition/dispo32

Admission criteria

›All confirmed spinal hematoma cases require admission

›No outpatient management for confirmed diagnosis

›All cases require inpatient neurological monitoring

›ICU admission indications

›Cervical or high thoracic lesions (T6 and above)

›Hemodynamic instability from neurogenic shock

›Respiratory monitoring for diaphragmatic compromise

›Autonomic dysreflexia risk

›Rapidly deteriorating neurological status

›Immediate post-operative monitoring

Surgical vs. conservative pathway

›Surgical pathway — emergent referral to neurosurgery

›Any moderate to severe neurological deficit

›Rapidly progressive deficit regardless of current severity

›ASIA Grade A, B, or C with compressive hematoma

›All cases where surgery within 12 hours of onset is achievable

›Conservative management consideration

›Mild or improving neurological deficits (Frankel D–E)

›73–84% of conservatively managed patients achieve complete recovery

›Requires serial neurological exams every 1–2 hours

›Immediate surgical backup available

›Repeat MRI to confirm hematoma resolution required

Transfer criteria

›Transfer to tertiary neurosurgical center

›Any patient with neurological deficit requiring surgery

›Transfer initiated while anticoagulation reversal in progress

›Do not delay transfer for complete workup — concurrent management during transport

08Treatment/t72

Anticoagulation reversal

›Warfarin reversal

›Four-factor prothrombin complex concentrate (4F-PCC) — first-line

›25–50 IU/kg IV

›Target INR <1.5 for neurosurgical intervention

›Do not wait for INR result before initiating in severe deficit

›Vitamin K IV

›10 mg IV slow infusion

›Sustained effect 12–24 hours after administration

›Administer concurrently with PCC for sustained reversal

›Dabigatran reversal

›Idarucizumab (Praxbind) — specific reversal agent

›5 g IV (two 2.5 g doses administered consecutively)

›Complete reversal within minutes

›First-line for dabigatran with life-threatening hemorrhage

›Factor Xa inhibitor reversal (rivaroxaban, apixaban, edoxaban)

›4-factor PCC — 25–50 IU/kg IV

›Non-specific but effective

›Use if andexanet alfa unavailable or contraindicated

›Activated PCC (aPCC, FEIBA)

›Alternative if 4F-PCC unavailable

›Heparin reversal

›Protamine sulfate

›1 mg per 100 units of heparin administered in preceding 2–3 hours

›Maximum 50 mg single dose

›Administer slowly over 10 minutes — hypotension risk

›LMWH reversal

›Protamine sulfate — partial reversal (60–80% of anti-Xa activity)

›1 mg per 1 mg enoxaparin administered in preceding 8 hours

›Second dose 0.5 mg per 1 mg enoxaparin if aPTT remains prolonged

›Thrombocytopenia management

›Platelet transfusion target >100,000/microL for neurosurgical intervention

Surgical intervention

›Decompressive laminectomy with hematoma evacuation

›Definitive treatment for moderate to severe neurological deficits

›Surgical goal — complete decompression of spinal cord or cauda equina

›Timing target — within 12 hours of symptom onset for optimal outcome

›Ultraearly surgery <12 hours — 100% favorable outcomes in World Neurosurgery 2023 series

›69–92% of surgically treated patients achieve favorable outcomes

›Recovery depends primarily on preoperative neurological status and time to decompression

Blood pressure management

›Neurogenic shock treatment

›Isotonic crystalloid IV — 1–2 L bolus for initial resuscitation

›Norepinephrine — vasopressor of choice

›Initial dose 0.1–0.2 mcg/kg/minute IV infusion

›Titrate to MAP target >85 mmHg

›Address both hypotension and bradycardia components

›Atropine for hemodynamically significant bradycardia

›0.5–1 mg IV; repeat every 3–5 minutes

›Maximum 3 mg total

›Avoid aggressive hypertension — risk of rebleeding not established but prudent caution

Corticosteroids

›Corticosteroid use in spinal cord injury

›Methylprednisolone high-dose protocols — not routinely recommended for spinal hematoma

›Evidence base is for traumatic spinal cord injury — not directly applicable

›Decision individualized in consultation with neurosurgery

›Dexamethasone — used perioperatively for edema reduction at surgeon discretion

Supportive care

›Bladder management

›Urinary catheterization for retention or monitoring

›Indwelling Foley or intermittent catheterization

›DVT prophylaxis

›Mechanical prophylaxis immediately — sequential compression devices

›Pharmacologic prophylaxis timing — neurosurgical clearance required after hemostasis confirmed

›Resumption of anticoagulation — multidisciplinary discussion weighing thrombotic vs. hemorrhagic risk

›Skin protection

›Pressure injury prevention — repositioning every 2 hours

›Specialty mattress for paralyzed patients

›Bowel regimen

›Prophylactic laxatives for paralytic ileus risk

›Stool softener — avoid Valsalva straining

Post-operative monitoring

›Neurological reassessment

›ASIA grading repeat within 24 hours post-operatively

›Serial exams to document recovery trajectory

›MRI timing

›Repeat MRI at 4–6 weeks to confirm hematoma resolution

›Earlier imaging if neurological deterioration post-operatively

09Special Populations/sp68

Pregnancy

›Incidence in pregnancy

›Relatively rare — estimated 1:200,000 risk

›Hypercoagulable state during pregnancy may be relatively protective

›Third trimester and peripartum period — highest risk window

›Pathophysiology considerations

›Venous engorgement of epidural venous plexus from IVC compression

›Labor-associated Valsalva forces elevate epidural venous pressure

›Epidural analgesia procedures add procedural risk

›Diagnosis

›MRI without gadolinium preferred — gadolinium crosses placenta

›MRI safe in pregnancy when clinically indicated — no ionizing radiation

›CT avoided if possible — ionizing radiation risk to fetus

›Treatment considerations

›Anticoagulation reversal — standard agents as in non-pregnant (with obstetric consultation)

›Warfarin avoided in pregnancy — use heparin-based products instead

›Vitamin K safe in pregnancy

›4F-PCC — limited pregnancy data, use in life-threatening hemorrhage

›Surgical decompression — not contraindicated in pregnancy

›Obstetric and anesthesia co-management required

›Fetal monitoring during surgery

›Positioning — avoid supine hypotension from aortocaval compression

›Left lateral tilt or manual uterine displacement

Geriatric

›Epidemiology in elderly

›Peak incidence in 6th decade — highest risk age group for spontaneous SSEH

›Elderly women at highest risk for procedure-related hematoma

›1:3,600 risk for epidural hematoma in knee arthroplasty setting

›Anticoagulation for atrial fibrillation and VTE is a key risk factor in this population

›Physiologic considerations

›Degenerative spondylosis narrows canal — smaller hematoma causes greater compression

›Reduced spinal cord reserve — higher severity of deficit for equivalent lesion size

›Osteoporotic deformities alter normal anatomy

›Polypharmacy increases anticoagulant and antiplatelet burden

›Anticoagulation reversal in elderly

›Renal impairment — affects DOAC clearance; longer reversal effect may be needed

›Hepatic disease — affects vitamin K-dependent clotting factor production

›Standard reversal protocols applicable with dose-adjusted monitoring

›Surgical risk

›Higher perioperative risk — cardiovascular, pulmonary, and anesthetic comorbidities

›Anesthesia consultation preoperatively for risk stratification

›Conservative management more frequently considered in mild deficit with high surgical risk

›Rehabilitation

›Slower functional recovery expected

›Higher rates of residual deficit compared to younger patients

›Early geriatric medicine and rehabilitation co-management

Pediatrics

›Epidemiology in children

›Second decade is one peak of bimodal age distribution

›Less common than adult presentation

›Spontaneous cases more frequent — vascular malformations and coagulopathy predominate

›Etiology differences

›Vascular malformations higher proportion — arteriovenous malformations, cavernous malformations

›Inherited coagulopathies — hemophilia A and B, von Willebrand disease

›Traumatic etiology proportionally higher

›Anticoagulant-related cases less common than adults

›Coagulopathy management

›Hemophilia A

›Factor VIII concentrate — target >100% activity for surgical hemostasis

›Recombinant products preferred

›Hemophilia B

›Factor IX concentrate — target >80–100% activity

›von Willebrand disease

›Desmopressin (DDAVP) 0.3 mcg/kg IV for Type 1

›von Willebrand factor concentrate for Type 2 and 3

›MRI considerations

›Sedation or general anesthesia often required in young children

›Full spine imaging — pediatric hematomas may be multilevel

›Surgical outcomes

›Generally better functional recovery than adults

›Spinal cord plasticity in pediatric age group

10Background/b67

Epidemiology

›Incidence

›Spontaneous spinal epidural hematoma (SSEH) incidence estimated at 0.1 per 100,000 per year

›Rare but potentially catastrophic neurological emergency

›Epidural space most common location

›Age and sex distribution

›Bimodal age distribution — peaks in 2nd and 6th decades

›Elderly women at highest risk for procedure-related hematoma

›No clear overall sex predominance for spontaneous cases

›Risk factor prevalence

›Anticoagulant or antiplatelet use present in 20–74% of cases depending on series

›Spinal vascular malformations found in ~15% on DSA

›Hypertension is an independent risk factor

›Spinal procedure-related cases — postoperative SSEH incidence after lumbar surgery 0.1–0.2%

›Classification by anatomical location

›Epidural — most common

›Blood accumulates between dura and vertebral column

›Posterior epidural space most frequent

›Subdural — less common

›Between dura and arachnoid

›ICD-10 G97.31

›Subarachnoid — uncommon; often associated with vascular malformation

›Intramedullary (hematomyelia) — rare; within cord parenchyma

›ICD-10 S14.109A

Pathophysiology

›Hemorrhage mechanism

›Epidural venous plexus rupture — Batson venous plexus lacks valves

›Pressure transmission with Valsalva elevates venous pressure acutely

›Arterial source in minority — anterior spinal artery branches

›Anticoagulation impairs hemostasis — unable to form stable clot at rupture site

›Vascular malformation — abnormal vessel rupture

›Cord injury mechanism

›Direct compression — mechanical deformation of cord or cauda equina

›Vascular compromise — compression of anterior spinal artery

›Ischemia at watershed zones — thoracic cord T4 and T8 most vulnerable

›Venous congestion — impaired venous drainage worsens edema

›Neurological deterioration cascade

›Hematoma expansion — active bleeding into closed spinal compartment

›Cord edema — vasogenic and cytotoxic edema below and at level

›Ischemia — compressive ischemia within hours if untreated

›Irreversible injury — axonal death after prolonged ischemia

›Prognostic determinants from evidence

›Preoperative ASIA grade — strongest prognostic factor

›ASIA Grade A at presentation — poorest prognosis regardless of surgical timing

›Time from neurological deficit to surgery — second strongest determinant

›Anticoagulant-associated hematomas — independently associated with worse surgical outcomes (warfarin)

›Cervical location — risk of respiratory failure adds morbidity

Therapeutic Considerations

›Surgical decompression evidence

›Decompressive laminectomy with hematoma evacuation — definitive treatment

›69–92% favorable outcomes in surgical series — In Vivo 2024; Acta Neurochirurgica 2024

›Ultraearly surgery <12 hours — World Neurosurgery 2023 series showed 100% favorable outcomes

›Compared to 63.6% for delayed surgery in same series

›Neurosurgical Review 2022 meta-analysis — confirmed time-to-surgery as major prognostic factor

›Conservative management evidence

›Selected patients with mild deficits or improving exam

›73–84% achieve complete recovery without surgery — Neurology 2022 multicenter series

›Requires serial neurological monitoring every 1–2 hours with immediate surgical backup

›Hematoma resolution confirmed on repeat MRI

›Anticoagulation reversal evidence

›ACC 2017 Expert Consensus Decision Pathway — reversal algorithm for oral anticoagulants

›ASRA 2025 Guidelines — regional anesthesia in patients receiving antithrombotic therapy

›Defines drug-free intervals before and after neuraxial procedures

›AHA/ASA 2022 ICH Guideline — reversal principles applicable to spinal hemorrhage

›Target INR <1.5 before neurosurgical intervention

›Platelet target >100,000/microL before neurosurgical intervention

›ICD-10 coding

›Spinal epidural hemorrhage — G97.31 (post-procedural), S14.0XXA (traumatic cervical)

›Spinal hematoma — use appropriate hemorrhage code by location

›Spinal cord injury level codes — S12–S34 by region

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Discharge information for patients managed conservatively or post-operatively

›You were treated for a spinal hematoma — bleeding around your spinal cord

›Your recovery may continue for weeks to months

›Physical therapy and rehabilitation are an important part of your recovery

›Medications

›Take all prescribed medications exactly as directed

›Your anticoagulant medication may have been changed or stopped — follow the instructions from your specialist

›Do not restart any blood thinners without clearance from your spine doctor

›Activity restrictions

›No heavy lifting, straining, or Valsalva maneuvers until cleared by your surgeon

›No driving until cleared by your physician

›Use assistive devices as recommended by your physical therapist

›Follow-up appointments

›Neurosurgery follow-up within 2–4 weeks of discharge

›MRI spine follow-up at 4–6 weeks to confirm hematoma resolution

›Physical therapy and rehabilitation referral as arranged

›Return to emergency department immediately for

›Any new weakness in arms or legs

›Numbness or tingling that is new or worsening

›Inability to urinate or loss of bladder or bowel control

›Severe new neck or back pain

›Difficulty breathing or swallowing

›Fever above 38.5 degrees Celsius

›Wound redness, swelling, or drainage if surgery was performed

›Warning signs requiring immediate call to 911

›Sudden paralysis or inability to move limbs

›Inability to breathe

12References/r27

Guidelines and key sources

›Primary evidence base

›Peng D et al. Prognostic Factors and Treatments Efficacy in Spontaneous Spinal Epidural Hematoma. Neurology 2022.

›Multicenter retrospective study — key prognostic factors and treatment outcomes

›Vastani A et al. Prognostic Factors and Surgical Outcomes of Spontaneous Spinal Epidural Haematoma. Neurosurgical Review 2022.

›Systematic review and meta-analysis — surgical timing and outcomes

›Nakamura S et al. Ultraearly Hematoma Evacuation (<12 Hours) Associated With Better Functional Outcome. World Neurosurgery 2023.

›100% favorable outcomes with surgery <12 hours

›Ropper AE, Ropper AH. Acute Spinal Cord Compression. NEJM 2017.

›Comprehensive review of spinal cord compression diagnosis and management

›Pierce JL et al. Spinal Hematomas: What a Radiologist Needs to Know. Radiographics 2018.

›MRI characteristics and imaging protocol for spinal hematoma

›Moriarty HK et al. MR Imaging of Spinal Haematoma: A Pictorial Review. British Journal of Radiology 2019.

›MRI signal evolution and sequence-specific findings

›Anticoagulation guidelines

›Kopp SL et al. ASRA Evidence-Based Guidelines 5th Edition. Regional Anesthesia and Pain Medicine 2025.

›Drug-free intervals and neuraxial procedure timing

›Tomaselli GF et al. 2017 ACC Expert Consensus on Bleeding in Patients on Oral Anticoagulants. JACC 2017.

›Reversal agent algorithms for warfarin and DOACs

›Greenberg SM et al. 2022 AHA/ASA Guideline for Spontaneous ICH. Stroke 2022.

›Reversal agent dosing applicable to spinal hemorrhage

›Classification and assessment tools

›Rupp R et al. ISNCSCI Revised 2019. Topics in Spinal Cord Injury Rehabilitation 2021.

›International Standards for Neurological Classification of Spinal Cord Injury

›Expert Panel on Neurological Imaging. ACR Appropriateness Criteria Myelopathy: 2021 Update. JACR 2021.

›MRI as Usually Appropriate for acute myelopathy workup

›Kumar N et al. Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants. World Neurosurgery 2024.

›Systematic review — anticoagulant and antiplatelet risk data

Evidence & Review

Evidence & Review