European Spine Journal - 2026-08-23 - Journal Article
Severe intraoperative bleeding as the initial manifestation of de novo immune thrombocytopenia during lumbar spinal fusion: a case report.
Mizukoshi R, Funao H, MIyamoto A, Ito K, Isogai N, Yagi M
Topics
Key Takeaway
De novo ITP presenting intraoperatively during L2-5 PLIF caused platelet nadir of 1,000/µL on POD1, refractory to transfusion and IVIG/steroids, with recovery only after thrombopoietin receptor agonist therapy.
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Summary
This case report documents an 81-year-old woman with normal preoperative platelets and coagulation who developed severe diffuse intraoperative bleeding during L2-5 PLIF for degenerative spondylolisthesis, with POD1 platelet count of 1,000/µL. Standard workup excluded heparin-induced thrombocytopenia, DIC, and drug-induced causes, yielding a diagnosis of de novo ITP. IVIG and corticosteroids failed; platelet recovery required thrombopoietin receptor agonist (TPO-RA) therapy, with no ITP recurrence at 1 year.
Key Limitation
A single case cannot establish causality between lumbar fusion and ITP triggering, nor distinguish surgical stress as precipitant from coincidental timing of de novo autoimmune disease.
Original Abstract
PURPOSE
Immune thrombocytopenia (ITP) rarely presents intraoperatively during spinal surgery. We report a case of de novo ITP that first manifested as severe, uncontrolled bleeding during lumbar spinal fusion despite normal preoperative platelet count and coagulation tests.
METHODS
The clinical course, perioperative laboratory findings, diagnostic workup, and treatment follow-up of an elderly woman who developed acute severe thrombocytopenia during L2-5 posterior lumbar interbody fusion were reviewed.
RESULTS
An 81-year-old woman underwent L2-5 posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis. Preoperative platelet count and coagulation parameters were normal. During intervertebral procedures, diffuse oozing bleeding progressively increased without apparent arterial injury, and intraoperative coagulation tests remained unremarkable. On postoperative day 1, the platelet count decreased to 1,000/µL and showed minimal response to platelet transfusion. After exclusion of other causes, de novo ITP was diagnosed. Intravenous immunoglobulin and corticosteroids were insufficient, but platelet recovery occurred after thrombopoietin receptor agonist therapy. Systemic bleeding manifestations included alveolar hemorrhage, purpura, and hematuria. No recurrence of ITP was observed at 1 year.
CONCLUSION
Acute ITP should be considered when unexplained diffuse intraoperative bleeding occurs during spinal surgery despite normal coagulation tests. Early reassessment of platelet counts and hematology consultation may facilitate timely diagnosis and treatment.