Bilateral subconjunctival haemorrhage in spinal cord injury: a case report

Abstract

Neurogenic lower urinary tract dysfunction is a common symptom after spinal cord injury. Here, the case of a 45-year-old male patient who was treated with indwelling urinary catheter during spinal surgery for a fall fracture injury of the T12 thoracic vertebra, associated with decreased muscle strength of both lower extremities, is described. During hospitalization in the rehabilitation department, conventional anticoagulation therapy was administered, and the urinary catheter was removed with the patient urinating by increasing abdominal pressure. At 8 days following urinary catheter removal, the patient was found to have a slight subconjunctival haemorrhage of the left eye, which gradually developed into massive subconjunctival haemorrhage in both eyes. After re-indwelling the urinary catheter, the bilateral subconjunctival haemorrhage gradually improved. No abnormal indicators were found during re-examination of coagulation function and platelet count, and the results of ophthalmological examination were normal. For patients with neurogenic bladder dysfunction associated with spinal cord injury, the risk of bleeding during the anticoagulation period should be carefully assessed to eliminate possible underlying bleeding risk factors (including past medical history and appropriate use of anticoagulant drugs) when considering spontaneous urination through the mode of abdominal pressure.

Introduction

The combination of neurogenic bladder associated with spinal cord injury poses a significant challenge to physicians regarding treatment and management. ¹ Patients with spinal cord injury are often prescribed anticoagulation therapy in the early stages to prevent the development of deep vein thrombosis in the lower extremities. ² However, the use of anticoagulant medication carries the risk of haemorrhage, which can be occult and easily overlooked. It is well established that increased vascular pressure may lead to vascular damage and subsequent bleeding. In the case of patients with spinal cord injury and neurogenic bladder, the Valsalva manoeuvre is commonly used to increase abdominal pressure and facilitate voluntary urination. ³ However, the incorrect execution of this manoeuvre, when combined with anticoagulant use, increases the risk of bleeding and presents further challenges in treatment. Therefore, it is crucial for patients with spinal cord injury and neurogenic bladder to receive proper training in voluntary voiding manoeuvres to minimize the risk of bleeding.

Case report

A 45-year-old male patient was admitted to the Spine Surgery Department of Tianjin Hospital, China, in July 2022, for spine surgery due to fall injury resulting in fracture of the T12 thoracic vertebra, with decreasing muscle strength of bilateral lower extremities. He underwent T12 laminectomy and posterior stabilization within 48 h after the injury (Figure 1a). The patient experienced functional impairments following the injury, such as an inability to actively dorsiflex both ankles, so he was transferred to the rehabilitation department for further recovery after surgery, where he was assessed as American Spinal Injury Association Impairment Scale grade D (motor incomplete). In addition to the T12 fracture, he also suffered multiple fractures of the pelvis and the left distal radius (Figure 1b), all of which were not operated (analgesic immobilization for pelvic fractures and fixation of radius fractures with braces). The patient had a 3-year history of type 2 diabetes mellitus and was taking medicines (100 mg sitagliptin and 1 mg repaglinide, both orally, once daily) for glycaemic control.

Figure 1.

X-ray images from a 45-year-old male patient with fall fractures, showing: (a) lumbar 3 vertebral body fracture; and (b) distal radius fracture.

The risk of venous thromboembolism was assessed prior to rehabilitation treatment using the Caprini risk assessment model, version 2013, ⁴ resulting in a score of 9 (very high risk). No abnormality was found in the routine coagulation examination, platelet count and ultrasonography of the deep veins of the lower extremities. The patient received 0.4 ml enoxaparin sodium (Clexane; Sanofi-Aventis, Paris, France) by subcutaneous injection, once daily, as preventive drug treatment. The patient was hospitalized with an indwelling urinary catheter because of neurogenic bladder after spinal cord injury. During physical examination, the cremasteric reflex and perineal sensation was found to exist in the patient, and he was able to spontaneously urinate by increasing abdominal pressure when the catheter was removed. Ultrasonography revealed a post-void residual urine volume of 21 ml, which met the criteria for catheter removal. On the 8th day after removal of the urinary catheter, the patient was found to have a little subconjunctival bleeding in the left eye, with no report of discomfort. The ophthalmological consultation recommended treatment with levofloxacin eye drops (Santen Pharmaceutical Co., Ltd. Osaka, Japan) and discontinuing enoxaparin sodium injection. Two days later, the patient had subconjunctival haemorrhage (temporal) in the right eye (Figure 2a). Ophthalmological examination revealed that the bilateral cornea, anterior chamber, pupil, lens and vision were normal. An indwelling catheter was placed again, both eyes were flushed with saline and levofloxacin eye drops were continued to prevent infection. The patient's conjunctival haemorrhage partially improved after indwelling the urinary catheter for 6 days (Figure 2b). No abnormality in coagulation function or platelet count was detected after re-examination of the patient. The patient was subsequently lost to follow-up.

Figure 2.

Facial images from a 45-year-old male patient who underwent T12 laminectomy and posterior stabilization due to fall fracture injury with decreasing muscle strength of bilateral lower extremities and neurogenic bladder, showing change in subconjunctival haemorrhage before (upper image) and after (lower image) indwelling catheter placement.

Ethics approval was not deemed necessary due to the case report study design and standard treatment applied. The patient provided written informed consent to treatment and for publication of the case and accompanying images. The reporting of this study conforms to CARE guidelines. ⁵

Discussion

Neurogenic lower urinary tract dysfunction is a common symptom after spinal cord injury. Despite evolving clinical diagnostic and management strategies, ¹ neurogenic bladder management remains challenging due to the complexity of spinal cord injury segments and patient comorbidities.

Neurogenic bladder refers to all disorders that may cause neuromodulation of urine storage and voiding, thereby affecting bladder and urethral dysfunction. ⁶ Common disorders include cerebrovascular disease, spinal cord injury, cerebral palsy, and diabetes. ⁷ Normal urination activity is completed by the spinal cord reflex centre and supraspinal reflex centre, and by sympathetic, parasympathetic and somatic nerves. ⁸ The global prevalence of neurogenic bladder caused by spinal cord injury is reported to be 1009/1 000 000. ⁹ Neurogenic bladder caused by spinal cord injury in different segments has a certain regularity, but it will affect the storage of urine and/or urinary function. ¹⁰ The patient in the current case presented with dysuria, thinning of urine flow and feeling of bladder fullness after injury, and the symptoms were consistent with the clinical manifestations of neurogenic bladder. The patient had normal blood pressure and did not experience any headaches during subconjunctival haemorrhage. Based on the clinical presentation, intracranial haemorrhage was not concluded to be a possibility. Thus, testing the patient's ferritin, or diagnosing Terson syndrome, were not considered at the time. ¹¹

For personal reasons, the patient was discharged the day after insertion of the urinary catheter. Consequently, follow-up and observation of the patient's eventual conjunctival regression could not be completed. Efforts in obtaining any further information were unsuccessful, despite making several attempts to follow-up with the patient through phone calls. Previous studies have found that acute spinal cord injury is a strong risk factor for venous thromboembolism, ² and the occurrence of deep vein thrombosis (DVT) is positively correlated with the degree of spinal cord injury. The risk of DVT in patients within 3 months of spinal cord injury is 16.9 times that of healthy people. The first choice for drug prevention and treatment of DVT in patients with spinal cord injury is currently low molecular weight heparin (LMWH). Although LMWH has obvious advantages in anticoagulation, it remains necessary to pay attention to the small probability of bleeding risk. As there is an international lack of evidence-based medicine for the dose and course of LMWH in preventing venous thromboembolism in patients with spinal cord injury, the anticoagulation course of the present case was based on the treatment standard of Chinese guidelines for the prevention of venous thromboembolism in orthopaedic major surgery. ¹² In a meta-analysis of LMWH-related bleeding, major bleeding occurred in 0.58% (72/12 486 patients), clinically relevant nonmajor bleeding occurred in 3.02% (377/12 486 patients) and minor bleeding occurred in 4.99% (314/6 286 patients). ¹³ In patients with non-major bleeding events, LMWH should be discontinued first, and the patient's anticoagulant drugs should be evaluated including: (1) whether anticoagulation exceeds the therapeutic range; (2) whether anticoagulation is within the therapeutic range; and (3) whether to provide continuous diagnosis of the bleeding site and clinical impact assessment as to whether the potential bleeding risk of the patient has changed (for example, due to the addition of new drugs, or the deterioration of liver and kidney function). ¹⁴

Many potential bleeding possibilities were ruled out in the present case, including family history of abnormal coagulation function, medication dosage and total course of treatment. We hypothesize that patients may hold their breath to increase abdominal pressure in order to facilitate urination, similar to the Valsalva manoeuvre. This manoeuvre may increase pressure in the heart and aorta within the thoracic cavity, ³ and also in smaller vessels, such as the ophthalmic veins. This increased pressure may potentially lead to a sudden rise in intraocular pressure, dilation of retinal capillaries, and even rupture and haemorrhage. The Valsalva manoeuvre was originally proposed by the Italian pathologic anatomist A.M. Valsalva in 1704. ¹⁵ In the present case, the patient was considered to frequently and excessively increase abdominal pressure to promote urination, thereby causing subconjunctival blood microvascular rupture and bleeding during the period of potential risk of haemorrhage while using anticoagulant drugs. There are no previously reported cases of subconjunctival haemorrhage due to increased abdominal pressure during anticoagulation therapy, but previous studies and observations suggest this as a potential but predictable risk factor. In 2015, Wang et al. ¹⁶ reported a case of aggravated conjunctival haemorrhage caused by the use of Chinese patent medicine preparations for promoting blood circulation and removing blood stasis in combination with aspirin. In an analysis of the causes of subconjunctival haemorrhage in 84 cases, hypertension, diabetes mellitus and history of cough were common comorbidities or possible causes of bleeding. ¹⁷ In particular, cough is one of the predictable and important factors that induce increased abdominal pressure. Vascular lesions are a common complication of diabetes, and anticoagulation therapy in patients with type 2 diabetes has been shown to increase the risk of kidney bleeding. ¹⁸ Therefore, the bleeding event in the present case was a combination of multiple potential bleeding risk factors, such as diabetes, anticoagulation therapy, and repeated increases in abdominal pressure.

For patients with spinal cord injury and neurogenic bladder during the anticoagulation period, the bleeding risk of the patient should be carefully evaluated (including prior medical history and whether anticoagulant drugs are properly administered), so that spontaneous urination through the mode of abdominal pressure may be avoided or reduced if necessary, and the factors of potential bleeding risk may be removed.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605231190547 - Supplemental material for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605231190547 for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report by Junqing Zhong, Weisheng Ye, Dan Meng and Yanwu Wang in Journal of International Medical Research

Supplemental Material

sj-pdf-2-imr-10.1177_03000605231190547 - Supplemental material for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report

Supplemental material, sj-pdf-2-imr-10.1177_03000605231190547 for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report by Junqing Zhong, Weisheng Ye, Dan Meng and Yanwu Wang in Journal of International Medical Research

Supplemental Material

sj-pdf-3-imr-10.1177_03000605231190547 - Supplemental material for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report

Supplemental material, sj-pdf-3-imr-10.1177_03000605231190547 for Bilateral subconjunctival haemorrhage in spinal cord injury: a case report by Junqing Zhong, Weisheng Ye, Dan Meng and Yanwu Wang in Journal of International Medical Research