Massive hematomyelia following intramedullary spinal cord tumor surgery

Abstract

Dear Editor, We would like to present an interesting case of postoperative hematomyelia following resection of an intramedullary spinal cord tumor (IMSCT) and discuss its clinical implications. Hematomyelia is a relatively rare phenomenon. Hematomyelia is mostly associated with traumatic insult, spinal vascular malformations such as intramedullary cavernous malformations [3, 10], or anticoagulation therapy [1, 9]. Clinical presentation varies from acute onset of spinal neurological deficits, accompanied by severe back or radicular pain, to chronic, slowly progressing neurological decline. A slow clinical course is usually associated with better prognosis [7]. Hematomyelia is a known presenting sign of spinal cord tumors [8]. It is also a rarely described complication of IMSCT surgery [2, 5]. Our patient was a 32-year-old male with a history of lung sarcoidosis presented with progressive sensorymotor disturbances of the lower limbs. MRI demonstrated multifocal pial lesions with a large intramedullary lesion at T6-7. Following rapid worsening of motor functions, he was operated upon. A subtotal resection of the lesion was performed. Pathology was consistent with low-grade glial tumor with pilocytic features. Following the first surgery, weakness on the right side improved. Eighteen months after surgery, a further decline in motor function was noticed. MRI demonstrated marked growth of the remnant tumor with homogenous enhancement and subependymal spread evident up to C6-7. The patient experienced rapid motor deterioration and underwent a second operation. A very generous subtotal re-resection was performed. Throughout the surgery, MEP and SSEP potentials monitoring remained uneventful. At the conclusion of surgery, the spinal cord was free of pressure with absolute hemostasis, and displayed pulsation and free CSF flow. Immediately following surgery the patient felt well, with evident motor improvement. However, on postoperative day 2 the patient attempted to get up from his bed unassisted and collapsed. A family member lifted the patient back to his bed. A few hours later the patient began suffering from severe back pain. In the following hours, the patient developed almost complete quadriplegia with minimal distal left hand movements. An emergency MRI revealed massive hematomyelia from the tumor site at T7 ascending all the way up to the foramen magnum (Fig. 1). A decision not to operate was made. The patient was intubated and transferred to the NICU. He underwent a tracheostomy, and over the next few weeks regained motor function in the upper limbs. The patient remains paraplegic however. B. Shofty : J. Roth :A. Korn : S. Constantini (*) Department of Pediatric Neurosurgery, Tel-Aviv Medical Center, 6th Weizman St., Tel-Aviv, Israel e-mail: sconsts@netvision.net.il