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PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1403-1405

EXPERIENCE AND REASON

Intramedullary Hemorrhage in a Neonate After Lumbar Puncture Resulting in Paraplegia: A Case Report

R. Shane Tubbs, MS, PA-C, PhD*,{ddagger}, Matthew D. Smyth, MD*, John C. Wellons, III, MD* and W. Jerry Oakes, MD*

* Pediatric Neurosurgery, Children’s Hospital, Birmingham, Alabama
{ddagger} Department of Cell Biology, University of Alabama at Birmingham, Birmingham, Alabama


   ABSTRACT
TOP
 ABSTRACT
CASE REPORT
 DISCUSSION
 REFERENCES
 
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
TOP
 ABSTRACT
 CASE REPORT
DISCUSSION
 REFERENCES
 
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.


Figure 1
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  		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.

 

Figure 2
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  		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
TOP
 ABSTRACT
 CASE REPORT
 DISCUSSION
REFERENCES
 
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 al2 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 al4 reported paraplegia in an elderly adult receiving antithrombotic therapy after epidural catheter placement. Gilbert et al5 reported epidural hematomas in healthy patients after epidural anesthesia. Pai et al6 reported an adult male who, after lumbar puncture, developed a subarachnoid hematoma with resultant paraplegia. Scott et al7 reported subarachnoid and subdural hematomas in patients after lumbar puncture. Interestingly, Bredtmann et al8 reported subarachnoid bleeding after spinal anesthesia after a previously undiagnosed spinal ependymoma was punctured. Intramedullary puncture after spinal puncture is reportedly rare. Farese et al9 reported the inadvertent injection of metrizamide into the cord after C1-C2 puncture. Mapstone et al10 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 al11 series. Rifaat et al12 reported the development of an intramedullary spinal abscess (Staphylococcus aureus) after spinal puncture for anesthesia before lower extremity surgery.


Figure 3
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  		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 Barson15 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
TOP
 ABSTRACT
 CASE REPORT
 DISCUSSION
 REFERENCES
 

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  3. 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][ISI][Medline]
  4. 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]
  5. Gilbert A, Owens BD, Mulroy MF. Epidural hematoma after outpatient epidural anesthesia. Anesth Analg. 2002;94 :77 –78[Abstract/Free Full Text]
  6. Pai SB, Krishna KN, Chandrashekar S. Post lumbar puncture spinal subarachnoid hematoma causing paraplegia: a short report. Neurol India. 2002;50 :367 –369[ISI][Medline]
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  8. 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]
  9. Farese MG, Martinez CR, Fisher CH. Inadvertent cervical cord puncture during myelography via C1-C2 approach. J Fla Med Assoc. 1990;77 :91 –93
  10. 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[ISI][Medline]
  11. Mamoli B, Sonneck G, Lechner K. Intracranial and spinal hemorrhage in haemophilia [in German]. J Neurol. 1976;211 :143 –154[CrossRef][ISI][Medline]
  12. Rifaat M, el-Shafei I, Samra K, Sorour O. Intramedullary spinal abscess following spinal puncture. Case report. J Neurosurg. 1973;38 :366 –367[ISI][Medline]
  13. Needles JH. The caudal level of termination of the spinal cord in American whites and American negros. Anat Rec. 1935;63 :417 –424[CrossRef]
  14. Rauzzino MJ, Iskandar B, Oakes WJ. Occult spinal dysraphism. Contemp Neurosurg. 1998;20 :1 –6
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  16. 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




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