|Year : 2020 | Volume
| Issue : 1 | Page : 123-126
Traumatic thoracic spine intramedullary hemorrhage: Rare spinal cord injury
Nitesh Gahlot, Abhay Elhence
Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
|Date of Submission||14-Dec-2018|
|Date of Decision||11-Mar-2019|
|Date of Acceptance||18-Sep-2019|
|Date of Web Publication||05-Feb-2020|
Dr. Nitesh Gahlot
Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan.
Source of Support: None, Conflict of Interest: None
The aim of this study was to report a rare case of post-traumatic thoracic spine intramedullary bleeding associated with spine fracture in the absence of compression due to fracture fragments on spinal cord. Magnetic resonance imaging scan showed thrombus formation inside the spinal cord with obliteration of neural elements. The patient was managed non-operatively and improved. Intramedullary hemorrhage in spinal cord is a rare cause of neurological deficit in post-traumatic cases and only a handful cases have been reported in the literature, giving no guidance regarding treatment of the condition. Conservative management can be considered a viable treatment option for intramedullary bleeds, especially in cases where there is no bony cord compression.
Keywords: Hematomyelia, intramedullary bleeding, spinal cord, thoracic hematomyelia, traumatic hematomyelia
|How to cite this article:|
Gahlot N, Elhence A. Traumatic thoracic spine intramedullary hemorrhage: Rare spinal cord injury. Indian Spine J 2020;3:123-6
| Introduction|| |
Spinal hematoma is a rare but serious condition that can culminate in death or permanent neurological deficit. Hence, timely diagnosis and management are important. The most common reported cause of spinal hematoma is idiopathic (30%), trauma being a very rare preceding event. The most common type is epidural hematoma (75%), followed by subarachnoid (15%) and subdural (4.1%). Intramedullary hematomas are very rarely reported in the literature (0.82%).
We report here a case of traumatic, intramedullary hematoma in thoracic spine associated with vertebral body fracture, causing severe neurological deficit. Because of rarity of this condition and associated severity of neurological damage, this diagnosis should be in the differential of every spine surgeon in emergency.
| Case Report|| |
A 45-year-old woman presented to the emergency department with complaints of back pain and bilateral lower limbs weakness following a fall from height of about fifteen feet. Clinical examination showed a midline spinal tenderness over the lower thoracic and lumbar spine with no obvious external injury. Neurological examination revealed reduced motor power in both lower limbs (hip 2/5, knee 3/5, and ankle 0/5). Deep tendon reflexes were absent below knee; plantar reflex was equivocal. There was no involvement of urinary bladder or bowel function. Sensory hypoesthesia was present below lumbar L2 level on the left side. Reduced movement coordination was noticed in both lower limbs with diminished fine touch, pain, and temperature sensation below thighs (American spinal injury association-C).
Radiology showed burst fracture of D7 and L1 vertebrae [Figure 1]. Computed tomography scan also corroborated with radiographic findings. It was noted that there was no canal compromise at both the fracture levels, which did not correlate with the amount of neurological deficit present clinically [Figure 2]. Hence, suspecting a cord injury, magnetic resonance imaging (MRI) scan was ordered. Multi-planar imaging of dorsolumbar spine was performed using T1, T2, and short inversion time inversion recovery (STIR) sequences by using 3.0T GE Discovery 750W MRI Scanner. Presence of T2 hyperintensity and swelling of the cord from D7 level to the level of conus occupying almost the entire spinal canal space were noticed, signifying diffuse cord edema/nonhemorrhagic contusion. There was heterogeneous short segment (5.7cm in length and 1.2cm in width) intramedullary T2 hypointensity and ballooning from D11 to L1 levels of spinal cord including the conus medullaris, signifying intramedullary cord hematoma [Figure 3],[Figure 4], [Figure 5].
|Figure 1: Radiographs of the patient showing compression fractures at D7 and L1 level|
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|Figure 2: CT scan sagittal image showing the fractured vertebral bodies. Note should be made that there is no intracanal fragment|
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|Figure 3: MRI sagittal T2W images of the spine showing the intramedullary thrombus|
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|Figure 4: MRI 3D sagittal T2-merged images showing the complete extent of thrombus|
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|Figure 5: MRI axial images depicting the intramedullary thrombus compressing the surrounding neural tissue|
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The blood coagulation profile of the patient was normal, along with other hemodynamic parameters. As no bony compression due to fracture fragments was seen on the spinal cord in imaging, patient was kept on conservative management with bracing and mobilization under the supervision of the physiotherapist. This involved passive and active leg mobilization initially, progressing to assisted standing with walking aid later in follow-ups. The patient was monitored by physical neurological examination during the follow-up visits at six weeks, three months, six months, and one year. The motor power had improved significantly (hip 4/5, knee 5/5, and ankle 3/5) at one-year follow-up visit, but not completely. Patient was able to walk with help of a walking aid. The back pain was very minimal (Visual Analog Scale [VAS] score 1) and occasional, requiring no analgesic medication.
| Discussion|| |
Hemorrhage is a rare diagnosis in spinal cord, as opposed to brain. Most authors follow the same classification of spinal hematomas as in brain, which is based on the primary location of the bleeding: intramedullary, subarachnoid, subdural, and epidural hemorrhages. The reporting of spinal cord hemorrhages has increased after the development of MRI due to increased diagnosis rate. Still the overall incidence remains less.
Krepple et al. reviewed all the studies that reported spinal cord hemorrhage and gave a lot of insight into this rare condition. They reported idiopathic as the most common cause (29.7%), followed by coagulopathy and vasculitis. Trauma with or without associated vertebral fracture was present in only 9.7% cases. According to location, epidural hematomas were the most common (75%), followed by subarachnoid and subdural hematomas. Intramedullary hematomas constituted only 0.82% of the cases.
Another review of spinal cord hemorrhages by Shaban et al. puts trauma as the most common cause, and vascular malformations and bleeding diathesis as most common cause for nontraumatic hemorrhage. They reported trauma as leading underlying cause for the intramedullary bleed also, but due to limited studies available they could not report the incidence. Overall, the major causes of traumatic hematomyelia include spine fractures and penetrating injuries. The major causes of nontraumatic hematomyelia include coagulopathy, arteriovenous malformations, syringomyelia and spinal cord tumors. The neurological deficit presentation is variable and depends on cause and location of the hemorrhage. The progression of deficit also varies from patient to patient.
Three cases of cervical spine traumatic intramedullary bleeding (hematomyelia) have been recently reported. Two of them were managed conservatively, and third report did not mention treatment modality. One case of thoracic spontaneous intramedullary bleed who developed acute paraplegia was reported by Akpinar et al. They performed a decompressive laminectomy and myelotomy to evacuate the thrombus, but the patient did not recover neurologically during the follow-up visits.
Surgical decompression of the spinal cord is preferred modality in spinal cord bleeds, but most of the studies report the commoner locations of bleed, that is, epidural, subarachnoid, and subdural. There is equivocal evidence for surgical intervention in intramedullary bleed and its evacuation, with fear of worsening of deficit because of surgical insult to already compromised vascular supply to cord. Hence, we decided to go with nonoperative approach as there was no compression over the cord in MRI images. The patient had improved neurologically at one-year follow-up visit. Although the conservative modality worked in our present case, there is a need to establish the correct treatment modality with larger studies involving more patients with intramedullary bleed.
| Conclusion|| |
Traumatic intramedullary bleed, although rare, is a serious condition, which can lead to permanent neurological deficit and disability to the patient. The diagnosis is MRI based. Conservative management can be considered a viable treatment option, especially in cases where there is no bony cord compression.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: A literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1-49.
Shaban A, Moritani T, Al Kasab S, Sheharyar A, Limaye KS, Adams HP, Jr. Spinal cord hemorrhage. J Stroke Cerebrovasc Dis 2018;27:1435-46.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]