Imaging recommendation · Neuro · Head & Neck

Acute back pain + neuro deficit on anticoagulation, suspected spinal epidural hematoma

Q: What's the alternative imaging for acute back pain + neuro deficit on anticoagulation, suspected spinal epidural hematoma when mri contraindicated and urgent surgery anticipated?

CT — CT Myelogram (iv contrast).

Recommended: MRI Spine without contrast (with gradient echo) is the preferred imaging study for acute back pain + neuro deficit on anticoagulation, suspected spinal epidural hematoma. Sudden severe back pain followed by radicular pain and progressive deficit.

Recommended study

MRI Spine without contrast (with gradient echo)

MRI No contrast Preferred Neuro · Head & Neck Emergency Reviewed 2026-05

Sudden severe back pain followed by radicular pain and progressive deficit. Iatrogenic (post-LP, post-epidural) or spontaneous (anticoagulation).

If the default doesn't apply

MRI contraindicated and urgent surgery anticipated

CT CT Myelogram IV contrast

Watch-outs

Time-to-decompression matters

Surgical decompression within 8-12 hours of deficit onset gives best neurologic recovery.

Anticoagulation reversal

Reverse warfarin (PCC / vitamin K) or DOAC (idarucizumab / andexanet) before surgery — coordinate with hematology.

Pearls

Most common in posterior epidural space; cervical and thoracic levels most affected.
Hyperacute hematoma may be isointense on T1 — gradient echo / SWI improves detection.
Spontaneous SEH is associated with anticoagulants, antiplatelets, vascular malformations, hypertension.