Disseminated intravascular coagulation in spine surgery: illustrative case review and the paradigms of management

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Disseminated intravascular coagulation (DIC) is rarely encountered by spine surgeons outside of deformity or severe trauma cases. The authors report an extraordinarily unique case of refractory DIC after elective resection of multiple en plaque thoracic meningiomas in a patient with neurofibromatosis type 1. A 49-year-old man underwent T1–3 laminoplasty and expansile duraplasty for resection of multiple en plaque meningiomas for thoracic myelopathy. Intraoperatively, the patient was found to be in a state of DIC that did not resolve postoperatively despite massive transfusions of blood products. He required subsequent returns to the operating room due to recurrent epidural hematomas with resulting paraplegia. Ultimately, the wound was left open, and a wound vacuum-assisted closure (VAC) was placed to prevent further returns to the operating room. DIC persisted until the administration of recombinant factor VIIa. In this report, the authors review the mechanisms, subtypes, and approaches to treatment of DIC with a focus on the bleeding subtype. If this subtype is refractory to blood product administration (> 24 hours), recombinant factor VIIa is a safe and effective option. A wound VAC can be safely utilized with exposed dura if deemed necessary by the surgeon; however, the volume and characteristics of the output should be closely monitored. The use of unconventional surgical solutions may provide options to mitigate the morbidity associated with refractory DIC in spine surgery.

ABBREVIATIONS AVM = arteriovenous malformation; DIC = disseminated intravascular coagulation; FDP = fibrin degradation product; FFP = fresh frozen plasma; INR = international normalized ratio; LMW = low-molecular-weight; PCC = prothrombin complex concentrate; POD = postoperative day; PRBC = packed red blood cell; rFVIIa = recombinant factor VIIa; VAC = vacuum-assisted closure.
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Contributor Notes

Correspondence Samir Kashyap: Riverside University Health System, Riverside, CA. skashyap41@gmail.com.INCLUDE WHEN CITING Published online October 11, 2019; DOI: 10.3171/2019.7.SPINE19756.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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