Fatal spontaneous spinal subdural hematoma in a patient on anticoagulant therapy

Spinal subdural hematoma (SSDH) is characterized by sudden onset neck and/or back pain, dysuria, and extremity impairment. The use of anticoagulants is a significant risk factor for SSDH, indicating that early diagnosis is crucial. However, achieving a timely diagnosis can be difficult owing to the rarity of this condition. The first forensic autopsy of a patient who died as the result of a spinal subdural hematoma (SSDH) is presented. A woman in her 70s undergoing anticoagulant therapy was transported to the emergency room with headache, back pain, and lower limb paralysis. The patient was initially diagnosed with spondylolisthesis and subsequently went into cardiac arrest. Her autopsy revealed an SSDH extending from the first thoracic vertebra to the cauda equina, with no associated tumors or vascular abnormalities. A retrospective examination of the patient's imaging and clinical history indicated missed opportunities for early diagnosis. The patient's cause of death was determined to be neurogenic shock due to progressive spontaneous SSDH. This case underscores the importance of early diagnosis and treatment of SSDH, particularly in patients undergoing anticoagulant therapy who are at an increased risk of spontaneous SSDH. Although some studies have suggested that conservative treatment may be effective for cases involving mild symptoms, surgical decompression is generally required for those with rapidly worsening symptoms. SSDH, therefore, should be considered in the differential diagnosis of patients presenting with back pain and neurological deficits, as delays in diagnosis and treatment can significantly affect patient outcomes.