Anticoagulation-Related Epidural Hematoma Causing Cauda Equina Syndrome After Posterior Lumbar Interbody Fusion: A Case Report

Abstract Background Postoperative spinal epidural hematoma (SEH) is a rare but potentially devastating complication of lumbar spine surgery, with an incidence of 0.1–0.4% [1, 2]. Anticoagulation therapy significantly increases this risk. The 2024 Chinese Expert Consensus on Diagnosis and Treatment of Spinal Epidural Hematoma emphasizes early recognition and timely surgical decompression as key to improving neurological outcomes. Case presentation: A 78-year-old Asian woman with a history of coronary stent implantation (2018) underwent posterior lumbar interbody fusion (L3–L5) for cauda equina syndrome. On postoperative day 3, she developed unstable angina, requiring initiation of therapeutic-dose enoxaparin (5000 IU subcutaneously every 12 hours). On postoperative day 5, approximately 6 hours after the onset of progressive perineal numbness and lower extremity weakness, she was diagnosed with postoperative SEH. A critical warning sign was a distinctive drainage pattern—40 mL on POD3 → 80 mL on POD4 (increased) → 15 mL on POD5 (sudden decrease), suggesting drain obstruction by clotted blood. Emergent surgical evacuation was performed within the 6-hour golden window recommended by the consensus, resulting in significant neurological recovery (muscle strength improved from grade 2 to grade 4). Conclusions This case highlights the delicate balance between anticoagulation for cardiac protection and bleeding risk prevention in elderly patients undergoing spinal surgery. Early recognition of warning signs—particularly sudden decreases in drainage volume—and emergent surgical decompression within 6 hours are critical for optimal neurological recovery. A multidisciplinary approach is essential.