A 25-Year-Old Man With Recurrent Back Pain and Rapid-Onset Paraplegia

Abstract

A 25-year-old man was transferred for evaluation and management of severe transverse myelitis. He had no pertinent past medical history. His symptoms started approximately 6 months earlier with new, substantial low back pain for 2 days, followed by a 3-day history of lower extremity weakness. He could only ambulate with the help of a rolling chair and had to discontinue work because of the severity of the weakness, but his symptoms resolved spontaneously within a few days. Findings of repeated spinal cord magnetic resonance imaging were consistent with evolution of a recent hemorrhage in the lower thoracic spinal cord. Digital subtraction angiography of the spinal canal showed normal findings, without evidence of arteriovenous malformation. Additional thorough evaluations for bleeding diatheses, drugs of abuse, thorough skin evaluation to exclude melanoma, and systemic imaging with computed tomography of the chest, abdomen, and pelvis and testicular ultrasonography were all normal. Given the clinical timeline, the lobulated hemorrhagic appearance of the lesion with a surrounding T2-hypointense rim and heterogeneous T1 and T2 signal indicating recent hemorrhage, no pattern on imaging to suggest a neoplasm, with negative systemic evaluation and normal digital subtraction angiography, a diagnosis of hematomyelia due to intramedullary spinal cavernous malformation was made. No neurosurgical management was recommended given the complete cross-sectional spinal cord injury at the level of hemorrhage, with potential risk of surgery with resection of the intramedullary spinal cavernous malformation. Short-interval follow-up imaging 3 weeks later showed expected evolution of the recent hemorrhage secondary to intramedullary spinal cavernous malformation. Hematomyelia may be caused by several potential mechanisms. The most common nontraumatic causes are attributable to cavernous malformations and arteriovenous malformations. Hematomyelia most commonly presents with acute back pain referable to the site of hemorrhage and myelopathy deficits with a range of severity (often severe).