Spinal epidural hematoma after a pathologic compression fracture: an unusual presentation of multiple myeloma

Delayed spinal epidural hematoma following T1 chance fracture: An illustrative case and review of the literature

Background

A Chance fracture is a traumatic fracture of the thoracic or lumbar spine that occurs secondary to a flexion-distraction injury. Although patients with chance fractures rarely present with neurologic deficits, a subset may become symptomatic from spinal epidural hematomas (SEH) warranting emergent decompressive surgery.

Case Description

An 87-year-old female on anticoagulation presented with a T1 Chance fracture after a fall. She was originally neurologically intact, but became paraplegic over the next 10 h. When the cervical/thoracic magnetic resonance revealed a SEH markedly compressing the cord between the C7-T1 levels, she underwent an emergent decompression; she also had a C5-T4 instrumented fusion. Postoperatively, she regained lower limb function, but expired on postoperative day 5 due to respiratory complications likely attributed to the prolonged surgery for the spinal instrumentation.

Conclusion

Delayed SEH rarely occur following spinal Chance fractures. Here, an 87-year-old female on anticoagulation developed the 10-h delayed onset of a SEH with paraplegia attributed to a T1 Chance fracture at the C7-T1 level. Although she regained neurological function following the emergent decompression, she expired 5 days later likely due to the extended operative time/blood loss from the C5-T4 fusion that could have been avoided.

Multiple myeloma with intracranial and spinal intradural metastasis: A case report

Multiple myeloma is a hematopoietic cancer that is multicentric and most commonly involves the spine. Multiple myeloma with extraosseous and intradural involvement is an extremely rare condition. Here we present a rare case of spinal multiple myeloma with intracranial and spinal intradural metastasis causing lumbar spinal nerve compression. We present a 60-year-old woman with progressive weakness of the lower limbs for several weeks. Spinal magnetic resonance imaging (MRI) showed a leptomeningeal tumor with nodularity spreading within the cauda equina. Examination of the brain using MRI showed a lytic skull bone lesion and leptomeningeal enhancement. The patient underwent L3-5 laminectomy. Immunohistological staining confirmed a diagnosis of multiple myeloma of the IgA kappa subtype. After surgery, the patient underwent chemotherapy and rehabilitation exercises. Multiple myeloma has a median survival of 2.5 years, while 75% of patients with spinal involvement die within 1 year of diagnosis. Unfortunately, our patient died 3 months after the diagnosis of multiple myeloma with spinal and intracranial involvement. Intracranial and spinal intradural multiple myeloma invasions are quitely rare. Spine biopsies and cerebrospinal fluid cytology can aid in the diagnosis. Early surgical decompression is necessary, especially when neurological deficits occur.

Acute Cervical and Thoracic Ventral Side Spontaneous Spinal Epidural Hematoma Causing High Paraplegia: A Case Report

Introduction

Spontaneous spinal epidural hematoma (SSEH) is a rare condition that can potentially cause paraplegia. SSEH has an increasing incidence rate and its cause remains unclear. Magnetic resonance imaging (MRI) results shows that SSEH presents a spinal epidural space-occupying lesion; therefore, emergency surgical treatment is required in some cases. MRI results of most SSEH cases showed that hematoma occurs in the dorsal or lateral side. By contrast, hematoma in the ventral side is very rarely shown.

Case Presentation

A 42-year-old healthy woman developed a sudden onset of severe neck pain with mild limb weakness, gradual breathing difficulty, and high paraplegia. MRI results revealed that an SSEH was compressing her spinal cord in the ventral epidural space from C2 to T3. Upon admission, she received emergency decompressive laminectomy in a posterior approach from C3 to T1, and the epidural hematoma was evacuated through full incision of the dorsal side dural, release of cerebrospinal fluid, and intermittent incision of the ventral side dural. The symptoms of limb paralysis and breathing distress gradually improved after recover rehabilitation, and the patient was discharged with life self-care after 2 months.

Conclusions

Performing early decompressive laminectomy and evacuation of hematoma on severe SSEH patients improves neurological outcomes. For patients with ventral side SSEH, the cerebrospinal fluid should be released after the incision on the dorsal side dural, and the ventral side dural should be gradually as well as intermittently clipped to evacuate the hematoma. The patient would also receive a good prognosis after the total release of the spinal cord compression.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

OBJECTIVE

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery.

SUMMARY AND BACKGROUND DATA

Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible.

CLINICAL REPORT

A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma.

CONCLUSION

Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Extraosseous epidural multiple myeloma presenting with thoracic spine compression

Multiple myeloma is a hematopoetic disorder and multicentric disease, with the most common localisation being the spine. A 47-year-old male presented with progressive paraplegia, superficial and deep sensory disturbance below the level of T4. Spinal magnetic resonance image showed an epidural mass compressing the spinal cord at the level of T4-T6 with intact bone structure. The patient underwent surgical T4-T6 posterior spinal decompression. Microscopic examination and immunohistochemical studies confirmed the diagnosis of multiple myeloma of kappa subtype. Immunoelectrophoresis revealed the presence of immunoglobulin G kappa. The patient was subsequently started on steroids and chemotherapy for myeloma. Extraosseous epidural tumors causing compression myelopathy without evidence of destruction or collapse of vertebral bodies are relatively rare; to our knowledge only four cases have been reported in English literature.

[An undiagnosed plasma cell myeloma. Complication after performing spinal anesthesia]

A male patient developed neurological deficits after an uneventful spinal anesthesia. After 2 months without any improvement an epidural hematoma was presumed. Magnet resonance imaging detected inflammatory tissue and destruction at lumbar levels L2/3. The inflammatory tissue had to be removed via laminectomy. Histology of the excised tissue revealed a plasma cell myeloma that was not diagnosed prior to spinal anesthesia 2 months previously.