Cauda equina syndrome in a patient on apixaban with a three-hour transfer

This is cauda equina syndrome with bilateral saddle anaesthesia, retention, and significant weakness, so decompression should be done as soon as safely possible; the evidence supports surgery within 24–48 hours, and earlier is better when deficits are progressive. The 36-hour history and 18 mm extrusion make delay risky. Apixaban was last taken 18 hours ago; with creatinine clearance 55, the half-life is prolonged. I would stop apixaban, check renal function and haemoglobin, and transfer immediately to the spinal unit. If surgery is planned within the next few hours, I would consider prothrombin complex concentrate or andexanet only if available and if the bleeding risk of surgery outweighs thrombotic risk; fresh frozen plasma is not a reliable reversal for factor Xa inhibitors. Neuraxial manipulation during full anticoagulation risks epidural haematoma. The practical plan is urgent transfer, repeat coagulation assessment, and decompression once coagulation is acceptable, without delaying for a morning theatre slot.

I would plan a posterior lumbar laminectomy or hemilaminectomy at L5-S1 with discectomy, not a minimally invasive tubular approach if the fragment is large and the canal is tight, because adequate decompression of the cauda equina is the priority. The 18 mm extrusion may require gentle manipulation around the S1 root and may be sequestered; I would confirm the level with intraoperative imaging. Postoperatively, bladder function is the key outcome: retention may recover over weeks to months, and a catheter or clean intermittent self-catheterisation plan should be arranged. I would tell him that saddle anaesthesia and bladder dysfunction may not fully recover, especially with a 36-hour delay, but that urgent decompression gives the best chance and prevents further progression. Motor recovery is more likely than sensory recovery. I would also explain the risks of dural tear, wound infection, recurrent disc, and epidural haematoma, and that anticoagulation will be resumed after surgery once haemostasis is secure.

I would restart apixaban only after surgery, once haemostasis is confirmed and drain output is low. For a patient with prior PE, thrombotic risk is significant, so a delay of 24–48 hours is reasonable but should be individualised. I would use mechanical prophylaxis early and mobilise with physiotherapy. Postoperative monitoring includes hourly neurological observations for the first 24 hours, with attention to new leg weakness, worsening saddle sensation, urinary retention, and severe back pain; an epidural haematoma is a surgical emergency. I would avoid NSAIDs and check haemoglobin if there is unexpected blood loss. Before discharge, the patient needs a bladder scan and a plan for intermittent catheterisation, wound review, and advice to return immediately for new weakness or incontinence. The apixaban restart should be discussed with the anticoagulation team, because renal function and the prior PE affect dosing; I would not simply restart the previous 5 mg twice daily without review.