A 22-yr-old man with no significant medical history presented with acute onset of paraparesis and bowel and bladder incontinence, occurring after a fall down four steps. Physical examination was remarkable in the bilateral lower limbs for strength 0/5, absent light touch, pinprick, and reflexes. International standards for neurological classification of spinal cord injury examination was consistent with a T5 AIS A spinal cord injury with no zone of partial preservation. Computed tomography abdomen/pelvis showed no bony abnormality or acute fracture but a high density of the spinal cord at T7–T12 levels with possible intradural or epidural cord compression. Follow-up magnetic resonance imaging of the thoracic spine showed an epidural hematoma at T5–T12, worst at T9–T11 with evidence of spinal cord compression (Fig. 1). Abdominal imaging further showed organomegaly consistent with lymphoma/leukemia. Laboratory results were significant for a leukocytosis of 169,000/μl and thrombocytopenia of 22,000/μl. These findings were consistent with a concurrent presentation of spinal cord injury and acute leukemia. The patient was transferred to another institution for final oncologic diagnosis and treatment and lost to follow-up.
Causes of traumatic spinal epidural hematomas include falls, motor vehicle accidents, assaults, spinal surgery, epidural catheter placement, and lumbar puncture. Nontraumatic or spontaneous spinal epidural hematoma may be associated with anticoagulation and antiplatelet medication, pregnancy, hemophilia, and, in few case reports, malignancy.
Our patient represents a case where relatively minor trauma caused a complete spinal cord injury, which lead to further work-up including laboratory tests and imaging and the diagnosis of acute leukemia. In this case, the malignancy likely plays a key role in the pathophysiology of this patient's presentation—with leukemia as the cause of thrombocytopenia, which led to a hematoma after only relatively minor trauma. We found one previous case report with similar circumstances whereby an acute spinal cord injury occurred in the setting of a fall followed by bending forward, which initiated severe back pain and progressed to gait dysfunction and urinary retention. In that work-up, the patient was diagnosed with AML as a contributing cause to the bleed. After surgical decompression, the patient was able to make full functional recovery.1 Another case report illustrates a patient with a new onset of leukemia (CML) in the setting of spontaneous spinal epidural hematoma and with thrombocytosis (platelets 596,000/μl) who benefited from surgical decompression in light of progressive symptoms while hospitalized.2 Other reports of epidural spinal hemorrhage in the setting of leukemia took place in already known diagnosis of malignancy and after a lumbar puncture.3,4
Our case is unique because of the severity of the spinal cord injury—a complete injury on International standards for neurological classification of spinal cord injury examination—in the setting of thrombocytopenia associated with leukemia. Our case illustrates why preventative guidance with regard to fall precautions is provided to patients with a diagnoses of leukemia or other causes of thrombocytopenia, which unfortunately were not given to our patient because such diagnosis was not known until after the fall. Surgical decompression can often improve neurologic outcomes in spontaneous spinal epidural hematoma; however, patients with complete injuries tend to benefit much less than those with incomplete injuries.5,6
1. Salvesen R: Spontaneous intraspinal epidural hematomas—report of 2 cases and review of the literature. Eur Neurol
2. Nojiri H, Kim S, Tsuji T, et al: Spontaneous spinal epidural hematoma as the initial presentation of leukemia. Eur Spine J
3. Hatzipantelis E, Kyriakidis I, Pavlou E, et al: Lumbar puncture complicated by spinal epidural hematoma in a child with leukemia. Clin Case Rep
4. Mapstone TB, Rekate HL, Shurin SB: Quadriplegia secondary to hematoma after lateral C-1, C-2 puncture in a leukemic child. Neurosurgery
5. Liao CC, Lee ST, Hsu WC, et al: Experience in the surgical management of spontaneous spinal epidural hematoma. J Neurosurg
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6. Yu JX, Liu J, He C, et al: Spontaneous spinal epidural hematoma: a study of 55 cases focused on the etiology and treatment strategy. World Neurosurg