Abstract
Three patients are presented with traumatic spinal cord injury (SCI) complicated by acute heterotopic ossification (HO), and concurrent deep vein thrombosis 15 months, 18 months and 22 years after SCI, accompanied by persistent hypercoagulation. The diagnosis of HO preceded deep vein thrombosis in all three patients. All were treated with etidronate disodium and therapeutic heparin followed by oral anticoagulation. As these patients were not acutely injured, the questions arose as to what predisposed them to deep vein thrombosis and when was the appropriate time to discontinue anticoagulation.
Over a course of 3 years following deep vein thrombosis, these patients were monitored for evidence of hypercoagulation by D-dimer assay, plasma fibrino-gen estimation, and rate of whole blood clotting by Sonoclot® coagulation analyzer. The activity of acute HO was assessed by three-phase bone scan. A steady state of hypercoagulation, reflected by an increase in all three parameters, ran parallel to the extent of acute HO for the entire observation period. Moreover, hypercoagulation was persistently greater during increased acute HO activity even when the warfarin-induced prothrombin time ratio was 1.2–1.5. In addition, as acute heterotopic ossification activity decreased, the test values returned to near normal during warfarin therapy. However, when warfarin was discontinued, the clotting rate and D-dimer levels were found to again increase. Oral anticoagulation was therefore resumed for these patients and will be continued as long as laboratory evidence of hypercoagulation is present.
The usual practice following an episode of thromboembolism is to discontinue anticoagulation after a fixed period of 3 months to 1 year. However in patients with SCI who have acute HO, the hypercoagulation may be long term. Laboratory monitoring can assist in identifying those patients who may require a prolonged regimen of anticoagulation. The possible role of acute heterotopic ossification in the development of clotting abnormalities is discussed.
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Perkash, A., Sullivan, G., Toth, L. et al. Persistent hypercoagulation associated with heterotopic ossification in patients with spinal cord injury long after injury has occurred. Spinal Cord 31, 653–659 (1993). https://doi.org/10.1038/sc.1993.105
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DOI: https://doi.org/10.1038/sc.1993.105