Transcription:
Case Report: COVID-19 Complication Leading to Spinal Hematoma

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we're examining a case report, COVID-19 complication leading to spinal hematoma.

Joining me is Dr. Anita Kou. She's a physiatrist at Northwestern Medicine's Marianjoy Rehabilitation Hospital. Dr. Kou, it's a pleasure to have you join us today. This is fascinating to me. So, tell us about this case regarding a COVID-19 complication that led to spinal cord injury. How was this found? What had been his treatment regimen? Tell us a little bit about this patient's symptoms and history with COVID-19.

Anita Kou, MD (Guest): Sure, thank you for the opportunity today, just to share this case. And I would like to credit my resident, Dr. Lira Donsendelhi, who's our third year physical medicine and rehabilitation resident at Marianjoy who really worked hard in putting this case together for us today, as well. So we had a patient who was 59 years old, a male who presented to our hospital initially with chest pain and shortness of breath after an episode of syncope. During his hospitalization in the acute care, they found that he had a massive saddle pulmonary embolism. And that is what led to the gold standard treatment of a fibrolytic agent, such as intravenous TPA. And that is unfortunately what kind of led to the spinal epidural hematoma.

There are rare cases of fibrolytic agents like TPA causing epidural hematomas. But this case is really unique because our patient came in with symptoms due to COVID-19 and had hypercoagulability from COVID-19 leading in the first place to this massive pulmonary embolus.

Host: Wow. That is so interesting. So, what is the incidence? You mentioned rare, what's the incidence of these types of complications, and you mentioned that the fibrolytic, the TPA has been known to cause this as a rare complication yes? But now we're including COVID into this.

Dr. Kou: Right. I mean, we were at this time just learning about the hypercoagulability risk with COVID-19 infections. And how they were causing venous thromboembolisms, strokes, maybe even myocardial infarctions. So, now that we know that and we have to treat pulmonary embolisms that are that large with TPA, it does bring up the concern of the risk of having bleeding as a rare complication versus the benefits of treating that embolism.

Host: So, now there's this risk of development of other serious complications. So, why did this particular case pose a challenging therapeutic decision for clinicians as far as timing, whether surgical intervention and the anticoagulation, despite that high risk. Tell us a little bit about how decisions were made and how you all work together to talk about this patient as far as treatment.

Dr. Kou: So, really the decision for the treatment came actually before our rehabilitation team was able to care for this patient. But I think, physicians in the acute care hospital have to make that decision to benefit the patient and making sure that, that risk of having poor outcome from a serious pulmonary embolism is treated quickly and aggressively.

I think what's really unique in this case is, despite there being the rare risk of having rare complication from the fibrinolytic treatment of this massive pulmonary embolism, the benefit really outweighed the risk at that time for treating this gentlemen.

Host: So what's the treatment plan as of now? What happened then afterward? And when you guys are working with this patient?

Dr. Kou: So, the patient fortunately was able to get to our acute inpatient rehabilitation center for his new, what we call non-traumatic spinal cord injury due to the spinal epidural hematoma. We did diagnose him with our standard spinal cord exam with a C-4 complete tetraplegia. And he underwent a three hour per day intensive physical therapy, occupational therapy and speech therapy for about a month.

We also had on staff, rehab psychology and spiritual care services, working with him and his family to help cope with the new diagnosis and changes. And we also held a family meeting early on, within the first two weeks of his stay, where the interdisciplinary team of therapists, nurse, rehab psychologist, case manager and I explained his diagnosis, prognosis and expectation for recovery as well as realistic goals to him and his family.

Host: Must've been devastating for his family to have this kind of a complication. What, in your opinion, made this case of spinal epidural hematoma, especially rare, and his history with COVID that further complicated, this case.

Dr. Kou: Yes. It was definitely difficult for him and his family. And I think it was really important that we were there educating and supporting him that it was a rare risk of him having this complication due to the hypercoagulability of COVID-19 leading to the venous thromboembolism and really just giving them hope and encouragement that his spinal cord injury recovery would progress over the next year with the help of intensive therapies, with the help of psychological treatment and adjustment coping with the new spinal cord injury.

Host: So, how long ago was this Dr. Kou and what's the outcome? How's he doing now?

Dr. Kou: So, this was probably about a year ago. he had progressed, requiring less assistance. He initially came to us, requiring total assistance and care for his mobility and activities of daily living. He also presented to us initially, with difficulty swallowing with dysphasia and had a gastrostomy tube in. That was able to be removed while he was here with us.

And he also had a tracheostomy due to respiratory insufficiency, also secondary to the epidural spinal hematoma and just how high his spinal cord injury was. But he did improve and progress towards capping of his tracheostomy by the time he left us

Host: That's such an interesting case. I appreciate you sharing this with us. So, what would you like physiatrists to learn from this case Dr. Kou as more COVID-19 related rehabilitation cases might arise?

Dr. Kou: Well, I think it's definitely important to educate and support our patients who may not understand this hypercoagulable risk of COVID-19 leading to venous thromboembolism. And in the setting of developing a rare, but this kind of devastating complication of fibrinolysis in the treatment of COVID-19 hypercoagulability, we can offer at least an interdisciplinary treatment approach in their spinal cord injury recovery; that does not only include physical, occupational, speech therapy, but also the importance of psychological treatment, of adjusting and coping with a new spinal cord injury and dedicated nursing education for the patient and his family. In this patient's case, given his severe spinal cord injury, our rehab program trained the patient, but also his family in how to care for him at home since he was requiring at least maximum assistance for everyday tasks and his mobility.

And I would like other physiatrists to be able to refer these patients who might've had a spinal cord injury indirectly from a COVID-19 infection; to know, to get them to a spinal cord injury center, a spinal cord injury physiatry team, and to also be able to provide that education and support.

Host: Thank you so much, Dr. Kou for joining us and sharing this very interesting case study. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rehab to get connected with one of our providers.

And that concludes today's episode of Better Edge, a Northwestern Medicine podcast for physicians. Please always remember to subscribe, rate and review this podcast and all the other fascinating Northwestern Medicine podcasts. I'm Melanie Cole.