1202 - Postoperative Hematoma Following High-Dose Lovenox for DVT Prophylaxis: Functional Recovery Through Inpatient Rehabilitation

Case Diagnosis: Traumatic atlantoaxial ligament disruption, anterior longitudinal ligament rupture, and transverse alar ligament injury following assault, status post occiput-C3 posterior instrumented fusion, complicated by postoperative cervical epidural hematoma and spinal cord compression.

Case Description: A 62-year-old male initially presented with neck and rib pain after an assault involving strangulation and body slamming with positive loss of consciousness. Imaging confirmed atlantoaxial instability, and he underwent occiput-C3 fusion. Postoperatively, he was started on lovenox 40 mg twice daily for DVT prophylaxis (weight: 57 kg). On postop day 3, he developed acute quadriparesis and urinary retention. MRI revealed cervical epidural hematoma with cord compression, prompting emergent C2-C6 laminectomy. Inpatient rehabilitation began once neurologically stable. Admission scores showed severe deficits (overall: 26; self-care: 8; mobility: 18). Over his stay, he achieved marked improvement (overall: 84; self-care: 28; mobility: 56), meeting or exceeding CMS risk-adjusted expectations.

Discussions: This case highlights a rare but devastating complication of postoperative spinal epidural hematoma associated with early, high-dose enoxaparin in a low-body-weight patient following cervical fusion. While chemoprophylaxis reduces venous thromboembolism risk, dosing in the immediate postoperative spine population, particularly after high cervical fusion, remains controversial. This case highlights the need for adherence to evidence-based prophylactic protocols that balance clot prevention with bleeding risk. It also demonstrates the critical role of early, intensive rehabilitation in optimizing neurologic and functional recovery after postoperative complications.

Conclusions: Careful selection and dosing of anticoagulants post-surgery is essential to mitigate hematoma risk. Even after severe neurologic decline from such complications, aggressive interdisciplinary rehabilitation can yield substantial recovery, enabling patients to achieve their expected functional outcomes. The author's case supports the physiatrist’s role in both complication mitigation through perioperative collaboration and maximal recovery through targeted rehabilitation.