Spontaneous cervical cord haemorrhage: an unusual presentation

Abstract

Spontaneous haemorrhage within or compressing the spinal cord is a rare condition that requires emergency investigation and treatment. Such a case presenting with rapidly progressive flaccid quadriparesis, with subsequent ventilatory failure is reported. In this case the patient probably had an unfortunate complication of hypertension and over-anticoagulation.A 65-year-old woman presented to her local district general hospital with sudden onset of neck pain of an hour's duration. Observations on admission included an irregular pulse of 90-100 bpm, blood pressure of 220/110 mm Hg and a temperature of 37.1˚C. Her initial neurological examination was unremarkable; however, over the following hour she developed severe dysaesthetic pain radiating down both arms. This was immediately followed by a rapidly progressive flaccid quadriparesis developing over only 30 min. A sensory level became apparent at C4 level. Throughout these developments, the patient remained alert and oriented with a Glasgow Coma Score of 15/15. The weakness was accompanied by ventilatory failure requiring endotracheal intubation, mechanical ventilation and sedation. Of note, her medical history included poorly controlled hypertension and refractory atrial fibrillation requiring atrioventricular nodal ablation, permanent ventricular pacing and lifelong anticoagulation. Her International Normalised Ratio was found to be abnormal at 5.2, but other laboratory investigations including inflammatory markers and white cell count were within normal limits.Her permanent pacemaker precluded MRI to investigate her myelopathy. For this reason she was taken for CT scanning of her head and the cervical spine. This showed no intracranial abnormality; however, there was a high attenuation lesion in the region of the C3/4 cord (fig 1) consistent with acute haemorrhage. Following a review of these images by the local neurosurgical service an arrangement was made for urgent transfer to the nearest neurosurgical centre.On arrival at the regional neurosurgical centre a decision was made to proceed directly to cervical laminectomy and exploration of the cervical spinal cord, in view of an inability to proceed to definitive imaging. In this way, extra-dural or intradural extraaxial pathology could be dealt with directly. Furthermore, if the pathology was intra-axial, a generous laminectomy would adequately decompress the involved segments of the spinal cord. Indeed following laminectomy, no collection could be identified even after division of the dura. The spinal cord was found to be oedematous and suffused, so a wide laminectomy (C3-C6) was carried out.Despite an initial complete quadriparesis and sensory level below C4, the patient made a slow but sustained neurological improvement through her stay at the critical care unit. Over a period of 3 months she was successfully weaned from mechanical ventilation, despite numerous setbacks, and regained power in both arms (MRC grade left 4/5, right 3/5) and both legs (MRC 2/5). There was also progressive improvement in all s...