PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1403-1405
Intramedullary Hemorrhage in a Neonate After Lumbar Puncture Resulting in Paraplegia: A Case Report
R. Shane Tubbs, MS, PA-C, PhD*,
,
Matthew D. Smyth, MD*,
John C. Wellons, III, MD* and
W. Jerry Oakes, MD*
* Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama
Department of Cell Biology, University of Alabama at Birmingham, Birmingham, Alabama
 |
ABSTRACT
|
|---|
We present the case of a premature infant with decreased spontaneous
movement of the lower extremities. Imaging was demonstrative
of a lesion of the conus medullaris. Operatively and with histologic
confirmation, the mass was determined to be a blood clot originating
from the conus. Retrospectively, the patient had a known lumbar
puncture. There were no clotting abnormalities in this patient.
At long-term follow-up, the child continues to have lower extremity
paresis and incontinence of bowel and bladder. Clinicians should
consider the lower termination of the conus medullaris in the
infant, especially in the preterm infant.
Key Words: cerebrospinal fluid • children • paralysis • spinal cord
Abbreviations: MRI, magnetic resonance imaging • CSF, cerebrospinal fluid
An altered neurologic examination in a premature neonate can be a subtle finding, especially in regard to extremity movement. The observation of spontaneous movement of the extremities in this age unless paralyzed is often very subjective. We report a premature neonate who, after transfer to our hospital from an outside institution, was observed to have decreased spontaneous movement of the lower extremities. Imaging studies revealed a mass lesion in the conus medullaris that at operation was found to be an iatrogenic hematoma.
|
CASE REPORT
|
|---|
We report a 22 weeks’ gestation male cared for initially
at an outside institution. His birth weight was
500 g. There
was no intraventricular hemorrhage or hydrocephalus documented.
For the first 4 months of life, the child did well and was on
room air with a reasonable pulmonary status despite the patient’s
overall history. At 17 weeks of age, the infant developed a
fungal infection of the blood. During this time, appropriate
antibiotics were administered and lumbar puncture showed no
meningitis. The evening after the lumbar puncture, the infant
was noted to have decreased spontaneous movement of the lower
extremities. The lumbar puncture performed at this time was
not documented to have been traumatic or difficult. The lumbar
puncture was documented as occurring in the L4-L5 vertebral
interspace. To address the patient’s lower extremity problem,
magnetic resonance imaging (MRI) was performed, which demonstrated
a 0.5
x 1.1-cm homogeneous mass in the conus medullaris. The
infant then was referred to our institution. Clotting times
both at the time of the lumbar puncture and on arrival to our
institution were within a normal range. The initial MRI was
not available at the time of arrival to our hospital. Once in
our care, MRI (Figs
1 and
2) verified the conus mass, which
had a differential diagnosis of tumor, abscess, or hemorrhage.
The conus terminated at the L3 vertebra. The distal cord and
filum terminale did not have normal cerebrospinal fluid (CSF)
pulsations. No dysraphism of the spinal column was observed.
Physical examination showed no cutaneous stigmata over the midline
lumbosacral spine indicative of occult spinal dysraphism. There
were normal spontaneous movements of the upper extremities and
only trace movement of either the left or right lower extremity.
The perineal floor was found to be paralyzed with paradoxical
movement. The patient then was taken to the operating room for
exploration of his conus mass. A laminectomy of the T12-L2 vertebrae
was performed. The dura mater centered over the underlying conus
was noted to have a small pinhole in which drops of CSF were
noted to egress. On opening the dura mater, a compressive spherical
mass was seen emanating from the conus medullaris into the surrounding
cauda equina. The extramedullary portion of this mass was dissected
from its surroundings and sent for pathologic examination. Operatively,
no pathologic entities such as arteriovenous malformation or
tumor were appreciated. Histologic analysis revealed a hemosiderin-laden
blood clot, described as acute without signs of inflammation.
The wound was closed in standard anatomic layers. Postoperatively,
the child was noted to move the lower extremities more vigorously
yet still with paresis of especially the right lower leg musculature.
At the 5-year follow-up, the patient continues to be incontinent
of bowel and bladder, has good iliopsoas function bilaterally,
has no function or sensation of the right lower extremity inferior
to the knee, and has 4/5 strength of all major muscles of the
left lower extremity. The patient wears bilateral ankle-foot
arthrodeses and can ambulate with assistance.
View larger version (112K):
[in this window]
[in a new window]
|
Fig 1. Coronal T1-weighted MRI illustrating the hyperintense mass of the conus medullaris (arrow). The uninvolved spinal cord is seen superior to the above-noted mass. The hyperdense vertebral elements are seen lateral to the intact spinal cord.
|
|
View larger version (138K):
[in this window]
[in a new window]
|
Fig 2. Axial T2-weighted (repetition time: 2000 milliseconds; echo time: 20 milliseconds) MRI of the vertebral column. Note the mass (arrow) depicted in Fig 1. Immediately anterior to this mass is a normal, hypodense region of CSF, with the posterior border of a hyperdense lumbar vertebra anterior to it.
|
|
|
DISCUSSION
|
|---|
Lumbar puncture is a therapeutic modality of widespread clinical
use. Complications from this procedure are seemingly rare. The
most common post lumbar puncture complication is headache. Spinal
hematoma, diplopia, and intraspinal dermoid tumor formation
are much less common problems.
1 Adler et al
2 reviewed all spinal
punctures associated with hematoma or hemorrhage from 1911 to
1998. Complications from this review included epidural, subdural,
and subarachnoid hematomas, usually in the setting of abnormal
coagulation. Only 5 of 64 cases discovered in their literature
review occurred after this diagnostic procedure in patients
without known risk factors. It has been posited that radicular
vessels are the most probable source of needle-induced blood
in lumbar punctures and not Batson’s plexus (Fig
3).
3 Darnat et al
4 reported paraplegia in an elderly adult receiving
antithrombotic therapy after epidural catheter placement. Gilbert
et al
5 reported epidural hematomas in healthy patients after
epidural anesthesia. Pai et al
6 reported an adult male who,
after lumbar puncture, developed a subarachnoid hematoma with
resultant paraplegia. Scott et al
7 reported subarachnoid and
subdural hematomas in patients after lumbar puncture. Interestingly,
Bredtmann et al
8 reported subarachnoid bleeding after spinal
anesthesia after a previously undiagnosed spinal ependymoma
was punctured. Intramedullary puncture after spinal puncture
is reportedly rare. Farese et al
9 reported the inadvertent injection
of metrizamide into the cord after C1-C2 puncture. Mapstone
et al
10 reported a patient with leukemia who developed a hematoma
with both extra- and intramedullary components and resultant
quadriplegia after a lateral C1-C2 puncture. Among 234 hemophiliacs,
1 patient (0.4%) developed an intramedullary hemorrhage after
spinal puncture in the Mamoli et al
11 series. Rifaat et al
12 reported the development of an intramedullary spinal abscess
(
Staphylococcus aureus) after spinal puncture for anesthesia
before lower extremity surgery.
View larger version (77K):
[in this window]
[in a new window]
|
Fig 3. Axial drawing as shown in Fig 2 through the lumbar spinal canal and contents. Note Batson’s venous plexus (arrows) enveloping the intraspinal contents and the radicular blood vessels in intimate contact with both the spinal cord and nerve rootlets.
|
|
Cord penetration after spinal puncture superior to the conus
medullaris will always be a potential complication. However,
knowledge of the termination of the normal conus tip, especially
in the young and preterm patient, is essential for avoiding
devastating consequences such as those illustrated in our patient.
The normal range in the termination of the spinal cord ranges
from the mid portion of the T12 vertebra to the lower portion
of the L3 vertebra.
13 These findings assume that occult spinal
dysraphism, which may tether the developing spinal cord inferiorly,
is not present.
14 Of 603 adult autopsies studied, only 9 patients
(1.5%) had the conus as low as the body of the L3 vertebra.
15 This anatomic distribution has been confirmed more recently
by MRI with termination of the spinal cord over the body of
L3 considered to be indeterminate with regard to pathologic
significance.
16 Barson
15 looked at the ascent of the spinal
cord in relation to the spine in fetal development and early
infancy. Of 258 subjects, approximately one half were between
28 and 40 weeks’ gestation. He found that the adult position
of the conus above the body of L3 was achieved by 2 months of
age after term gestation. The position of the spinal cord in
the last 15 weeks of normal in utero development showed progressive
ascent from L4 to L2. Today, when premature delivery and survival
are commonplace for neonates of 25 weeks’ gestation, this
more caudal position of the normal spinal cord must be kept
in mind during routine clinical care.
Although seemingly quite rare, our case illustrates the devastating consequences of lumbar puncture with iatrogenic injury to the spinal cord. The clinician should be aware of the normally more inferiorly placed conus medullaris in the neonate, especially those born prematurely.
|
FOOTNOTES
|
|---|
Received for publication May 12, 2003; Accepted Aug 18, 2003.
Address correspondence to R. Shane Tubbs, MS, PA-C, PhD, Pediatric Neurosurgery, 1600 7th Ave S, ACC 400, Birmingham, AL 35233. E-mail: richard.tubbs{at}ccc.uab.edu
|
REFERENCES
|
|---|
- Sternbach G. Lumbar puncture.
J Emerg Med. 1985;2
:199
–203[CrossRef][Medline]
- Adler MD, Comi AE, Walker AR. Acute hemorrhagic complication of diagnostic lumbar puncture.
Pediatr Emerg Care. 2001;17
:184
–188[CrossRef][Web of Science][Medline]
- Breuer AC, Tyler HR, Marzewski DJ, Rosenthal DS. Radicular vessels are the most probable source of needle-induced blood in lumbar puncture: significance for the thrombocytopenic cancer patient.
Cancer. 1982;49
:2168
–2172[CrossRef][Web of Science][Medline]
- Darnat S, Guggiari M, Grob R, et al. A case of spinal extradural hematoma during the insertion of an epidural catheter [in French].
Ann Fr Anesth Reanim. 1986;5
:550
–552[Medline]
- Gilbert A, Owens BD, Mulroy MF. Epidural hematoma after outpatient epidural anesthesia.
Anesth Analg. 2002;94
:77
–78[Abstract/Free Full Text]
- Pai SB, Krishna KN, Chandrashekar S. Post lumbar puncture spinal subarachnoid hematoma causing paraplegia: a short report.
Neurol India. 2002;50
:367
–369[Web of Science][Medline]
- Scott EW, Cazenave CR, Virapongse C. Spinal subarachnoid hematoma complicating lumbar puncture: diagnosis and management.
Neurosurgery. 1989;25
:287
–293[CrossRef][Web of Science][Medline]
- Bredtmann RD, Wright J, Weissflog M. A space-occupying hemorrhage following spinal anesthesia in the presence of an undiagnosed small spinal tumor (ependymoma) [in German].
Reg Anaesth. 1989;12
:38
–40[Medline]
- Farese MG, Martinez CR, Fisher CH. Inadvertent cervical cord puncture during myelography via C1-C2 approach.
J Fla Med Assoc. 1990;77
:91
–93
- Mapstone TB, Rekate HL, Shurin SB. Quadriplegia secondary to hematoma after lateral C-1, C-2 puncture in a leukemic child.
Neurosurgery. 1983;12
:230
–231[Web of Science][Medline]
- Mamoli B, Sonneck G, Lechner K. Intracranial and spinal hemorrhage in haemophilia [in German].
J Neurol. 1976;211
:143
–154[CrossRef][Web of Science][Medline]
- Rifaat M, el-Shafei I, Samra K, Sorour O. Intramedullary spinal abscess following spinal puncture. Case report.
J Neurosurg. 1973;38
:366
–367[Web of Science][Medline]
- Needles JH. The caudal level of termination of the spinal cord in American whites and American negros.
Anat Rec. 1935;63
:417
–424[CrossRef]
- Rauzzino MJ, Iskandar B, Oakes WJ. Occult spinal dysraphism.
Contemp Neurosurg. 1998;20
:1
–6
- Barson AJ. The vertebral level of termination of the spinal cord during normal and abnormal development.
J Anat. 1970;106
:489
–497[Web of Science][Medline]
- Wilson DA, Prince JR. MR imaging determination of the location of the normal conus medullaris throughout childhood.
AJR Am J Roentgenol. 1989;152
:1029
–1032[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
TOP
ABSTRACT
CASE REPORT
