Spinal intramedullary hematoma presenting years following a cervical epidural injection.

BACKGROUND: Intramedullary cervical cystic lesions are typically attributed to tumors, infection, or trauma. Here, a patient newly presented with quadriparesis due to a chronic cervical intramedullary hematoma attributed to a cervical epidural steroid injection (CESI) performed 4 years earlier. CASE DESCRIPTION: A 38-year-old patient had a CESI in 2014. Resulting in a transient quadriparesis attributed to an inadvertent intramedullary cord injection. Now, at age 42, she presented with a recurrent cervical myelopathy due to an MR-documented C3-C6 intramedullary cystic lesion that at surgery proved to be a chronic liquified hematoma rather than a syrinx.
CONCLUSION: CESI can result in inadvertent intramedullary hemorrhages and spinal cord injuries. Here, a 42-year-old female presented with recurrent myelopathy due to a chronic intramedullary C3-C6 cervical hematoma attributed a prior intramedullary CESI injection performed 4 years previously. Copyright:

INTRODUCTION

Intramedullary cervical cystic lesions are typically attributed to; intramedullary tumors, syringomyelia, hematomyelia, and intramedullary abscesses.[1,4,7,8] Here, we describe a patient with a recurrent quadriparesis due to an intramedullary chronic C3-C6 hematoma attributed to an inadvertent intramedullary cervical epidural steroid injection (CESI) performed 4 years ago.

CASE DESCRIPTION

A now 42-year-old patient underwent a CESI for neck pain in 2014. The procedure was aborted when she developed the acute onset of electrical shock sensations (Lhermitte’s Signs) running down the entire spine and a transient quadriparesis (i.e., that lasted 1 week). Four years later, the patient presented with a recurrent quadriparesis attributed to a cervical MRI-documented intramedullary cyst spanning the C3-C6 levels that did not enhance with contrast. Although the original diagnosis was an idiopathic syrinx, at surgery consisting of a myelotomy, it proved to be a chronic liquified hematoma [Figure 1]. Within the next 8 postoperative weeks, the patient’s motor strength and sensation improved, and the 8 MR confirmed adequate decompression of the cyst and residual C3-C6 myelomalacia.

Figure 1:

(a) Preoperative MRI T1 sequence of the cervical spine (sagittal view) shows a cystic lesion involving the cervical spinal cord (*). (b) Preoperative MRI T2 sequence of the cervical spine (sagittal view) shows a cystic lesion involving the cervical spinal cord (*). (c) Preoperative MRI T1 sequence with contrast of the cervical spine (sagittal view) shows a cystic lesion involving the cervical spinal cord (*). (d) Intraoperative image (×50) shows the midline myelotomy (*) to decompress the cyst. (e) Intraoperative image (×50) shows the old liquified hematoma emerging from the myelotomy (*). (f) Postoperative MRI T2 sequence of the cervical spine (sagittal view) shows the spinal cord after decompression of the intramedullary hematoma (*).

DISCUSSION

The differential diagnosis of intramedullary cervical cord cystic lesions include; primary and metastatic tumors, syringomyelia, hydromyelia, infection, and hematomyelia.[1,4,7,8] CESI may contribute to spinal epidural hematomas and intramedullary cord injections/hematomyelia.[2,3,5,6,9] In this case, the patient’s the MRI-documented intramedullary C3-C6 cystic lesion proved at surgery (i.e. midline myelotomy) to be a chronic intramedullary hematoma. In retrospect, it was attributed to the CESI performed 4 years previously.

CONCLUSION

Delayed chronic spinal cord intramedullary hematomas can develop, as in this case, up to 4 years following CESI. Here, direct surgical decompression resulted not only in neurological improvement, but also confirmed the diagnosis of an intramedullary hematoma attributed to the prior CESI.