- Email: [email protected]
Spinal varicosities complicated by pregnancy
Spinal varicosities
complicated
by pregnancy
Case report
ROBERT
J.
ROBERT
C.
DONALD
SMITH,
CHARLES
OLIVER,
M.D.
GREENWOOD,
M.D..
F.A.C.S.
M.D.
FRANKLIN,
M.D.,
F.A.C.O.G.
Tucson, Arizona
B A c K AC H E with radiculitis is not an unusual complaint in pregnancy and is usually of postural origin. We present here a patient with backache of unusual origin, and its complications in pregnancy. This gravida iv, para iii 19-year-old housewife was initially seen at 30 weeks’ gestation complaining of low bachache and “pain in the left leg.” A positive Lasegue sign without other findings was present. She was not seen again for that pregnancy, but stated that the symptom progressed to involve her right leg and walking became difficult. All symptoms regressed postpartum. When she was next seen, Nov. 12, 1963, she complained of “weak” bones and legs. Hyperreflexia was found. The following day she was admitted with a history of 2 weeks of dull pain in the left leg to the foot and 2 days of severe pain bilaterally. For approximately 12 hours there had been “paralysis” and extreme pain circumanally. She screamed with pain on any movement. The blood pressure was 110/60; pulse, 94; fundus at 28 cm.; the fetal heart tones were normal, and the fetus was in vertex presentation. Pretibial edema was present. Marked lower extremity, inguina1, and vulvar varicosities were found. Extreme agitation prevented adequate neurological evaluation. However, hyperesthesia below T-,, was reFrom the Debartments of Obstetrics Gynecology and Neurosurgery, San Diego County Hospital, San Diego, California.
markable. Deep tendon reflexes were normal in the upper extremities, but exaggerated in the lower extremities. Bright red blood was obtained at different levels with a lumbar tap. The laboratory findings were : hemoglobin 9.8 Gm.; hematocrit 30 per cent; white blood count 11,900 with normal differential; and blood urianitrogen, 8 mg. per cent. In the cerebrospinal fluid the hematocrit was 9 per cent; 10,800 white blood cells. The VDRL test was negative and the chest x-ray was negative. The patient’s vital signs remained stable in spite of increasing agitation. Sacral segment one pain distribution and paralysis from spinal segment L-, downward became evident. Repeat lumbar puncture revealed 1 million red blood cells; white blood count 25,000; polymorphonuclear leukocytes 90 per cent; lymphocytes 10 per cent; and protein 400 mg. per cent. The condition deteriorated with loss of urinary continence and complete flaccidity of lower extremities. The fetus was apparently uninvolved. On November 21, the neurological department requested termination of pregnancy. A 3 pound, 8 ounce maIe was delivered by low cervical cesarean section. The amniotic fluid was meconium stained. The infant survived 36 hours. The bladder, broad ligaments, tuboovarian ligaments, and pelvic floor were covered by immense venous channels, and bleeding was profuse. Emergency supracervi-
and
258
Volume 94 Number
Spinal
2
cal hysterectomy was carried out. There was no progression of her disease postpartum. By November 30, the patient was ambulatory to a wheel chair. Constant bladder drainage continued. A myelogram on December 6 revealed that the pressure was 146 cm. H,O; the cerebrospinal fluid was xanthochromic; and protein was 620 mg. per cent. A “space-occupying lesion” was noted on the inferior aspect of L,. Electrometer force, on December 13, revealed a severe lower motor neuron lesion at the L, and L, levels. She was discharged. Readmitted December 30, she demon-
Fig.
1. Drawing
made
at the time
of operation
varicosities
259
strated slight improvement in use of her legs and could bear weight with balance aid. Hyperesthesia from neural segments L, through S, and complete paresis from L, downward continued. Deep tendon reflexes in the knees were normal on the left and “brisk” on the right. Repeat myelogram confirmed an “intramedullary” lesion at L,. Exploration of the spinal cord on January 22 (Fig. 1) revealed a thrombosed mass in the vicinity of L, interspace meshed with large tortuose varicose vessels and “milk” adhesions. One large vessel came from L, on the left side. The cord was stained yellow
showing
vascular
lesion
at the Lx-L2
level.
260
Oliver
et al.
and the nerve roots were tangled among the varicose vessels. Ligation was impossible. Postoperatively, the sensation of paresis improved and physical therapy was directed at bilateral foot drop and gait training. She was continent of urine by May and now is carrying out normal housework. Comment The vascular anatomy of the spinal cord is composed of veins from the inferior of the cord united in a plexus on the surface upon which are six main longitudinal channels posteriorly and anteriorly. These emerge along nerve roots and empty into the vertebrae, intercostal, lumbar, and sacral veins. Drainage is through the posterior system of veins.’ Most frequent vascular malfunctions affecting the spinal cord are angiomatous malformations and spinal epidural hemangiomas.
The former are ram, the latter may increase in volume during pregnancy, lead to cord compression, and regress postpartum. They will reappear with each pregnancy.” Thrombosis of the spinal vesseIs results most often from syphilis, trauma, collagen disease, tuberculosis, and malignant disease. Subacute necrotizing myelitis is possible, but usually is progressively downhill. Our patient’s problem was spinal varicositis. This situation was aggravated by pregnancy and thrombosis due to stasis. The symptomatology in each pregnancy began when pelvic congestion and stasis due to the gravid uterus became evident. In this pregnancy, thrombosis and hemorrhage occurred resulting in transverse myelitis. Grinker’ states that paresthesias in Iesions of the cord tend to be a “single modality of With this patient, before hemorsensation.” rhage and thrombosis this was evident.
REFERENCES
1.
2.
Grinker, R. R., Bucy, P. C., and Sah, A. L.: Neurology, Springfield, Illinois, 1960, Charles C Thomas, Publishers. Guttmacker, A. F., and Rovinsky, J. J.: Medical, surgical and gynecological complications
of pregnancy, Baltimore, Williams & Wilkins Company. Suite 125 W¬ Medical Tucson, Arizona
Bldg. 8571 I
Maryland,
1960,
complicated
by pregnancy
Case report
ROBERT
J.
ROBERT
C.
DONALD
SMITH,
CHARLES
OLIVER,
M.D.
GREENWOOD,
M.D..
F.A.C.S.
M.D.
FRANKLIN,
M.D.,
F.A.C.O.G.
Tucson, Arizona
B A c K AC H E with radiculitis is not an unusual complaint in pregnancy and is usually of postural origin. We present here a patient with backache of unusual origin, and its complications in pregnancy. This gravida iv, para iii 19-year-old housewife was initially seen at 30 weeks’ gestation complaining of low bachache and “pain in the left leg.” A positive Lasegue sign without other findings was present. She was not seen again for that pregnancy, but stated that the symptom progressed to involve her right leg and walking became difficult. All symptoms regressed postpartum. When she was next seen, Nov. 12, 1963, she complained of “weak” bones and legs. Hyperreflexia was found. The following day she was admitted with a history of 2 weeks of dull pain in the left leg to the foot and 2 days of severe pain bilaterally. For approximately 12 hours there had been “paralysis” and extreme pain circumanally. She screamed with pain on any movement. The blood pressure was 110/60; pulse, 94; fundus at 28 cm.; the fetal heart tones were normal, and the fetus was in vertex presentation. Pretibial edema was present. Marked lower extremity, inguina1, and vulvar varicosities were found. Extreme agitation prevented adequate neurological evaluation. However, hyperesthesia below T-,, was reFrom the Debartments of Obstetrics Gynecology and Neurosurgery, San Diego County Hospital, San Diego, California.
markable. Deep tendon reflexes were normal in the upper extremities, but exaggerated in the lower extremities. Bright red blood was obtained at different levels with a lumbar tap. The laboratory findings were : hemoglobin 9.8 Gm.; hematocrit 30 per cent; white blood count 11,900 with normal differential; and blood urianitrogen, 8 mg. per cent. In the cerebrospinal fluid the hematocrit was 9 per cent; 10,800 white blood cells. The VDRL test was negative and the chest x-ray was negative. The patient’s vital signs remained stable in spite of increasing agitation. Sacral segment one pain distribution and paralysis from spinal segment L-, downward became evident. Repeat lumbar puncture revealed 1 million red blood cells; white blood count 25,000; polymorphonuclear leukocytes 90 per cent; lymphocytes 10 per cent; and protein 400 mg. per cent. The condition deteriorated with loss of urinary continence and complete flaccidity of lower extremities. The fetus was apparently uninvolved. On November 21, the neurological department requested termination of pregnancy. A 3 pound, 8 ounce maIe was delivered by low cervical cesarean section. The amniotic fluid was meconium stained. The infant survived 36 hours. The bladder, broad ligaments, tuboovarian ligaments, and pelvic floor were covered by immense venous channels, and bleeding was profuse. Emergency supracervi-
and
258
Volume 94 Number
Spinal
2
cal hysterectomy was carried out. There was no progression of her disease postpartum. By November 30, the patient was ambulatory to a wheel chair. Constant bladder drainage continued. A myelogram on December 6 revealed that the pressure was 146 cm. H,O; the cerebrospinal fluid was xanthochromic; and protein was 620 mg. per cent. A “space-occupying lesion” was noted on the inferior aspect of L,. Electrometer force, on December 13, revealed a severe lower motor neuron lesion at the L, and L, levels. She was discharged. Readmitted December 30, she demon-
Fig.
1. Drawing
made
at the time
of operation
varicosities
259
strated slight improvement in use of her legs and could bear weight with balance aid. Hyperesthesia from neural segments L, through S, and complete paresis from L, downward continued. Deep tendon reflexes in the knees were normal on the left and “brisk” on the right. Repeat myelogram confirmed an “intramedullary” lesion at L,. Exploration of the spinal cord on January 22 (Fig. 1) revealed a thrombosed mass in the vicinity of L, interspace meshed with large tortuose varicose vessels and “milk” adhesions. One large vessel came from L, on the left side. The cord was stained yellow
showing
vascular
lesion
at the Lx-L2
level.
260
Oliver
et al.
and the nerve roots were tangled among the varicose vessels. Ligation was impossible. Postoperatively, the sensation of paresis improved and physical therapy was directed at bilateral foot drop and gait training. She was continent of urine by May and now is carrying out normal housework. Comment The vascular anatomy of the spinal cord is composed of veins from the inferior of the cord united in a plexus on the surface upon which are six main longitudinal channels posteriorly and anteriorly. These emerge along nerve roots and empty into the vertebrae, intercostal, lumbar, and sacral veins. Drainage is through the posterior system of veins.’ Most frequent vascular malfunctions affecting the spinal cord are angiomatous malformations and spinal epidural hemangiomas.
The former are ram, the latter may increase in volume during pregnancy, lead to cord compression, and regress postpartum. They will reappear with each pregnancy.” Thrombosis of the spinal vesseIs results most often from syphilis, trauma, collagen disease, tuberculosis, and malignant disease. Subacute necrotizing myelitis is possible, but usually is progressively downhill. Our patient’s problem was spinal varicositis. This situation was aggravated by pregnancy and thrombosis due to stasis. The symptomatology in each pregnancy began when pelvic congestion and stasis due to the gravid uterus became evident. In this pregnancy, thrombosis and hemorrhage occurred resulting in transverse myelitis. Grinker’ states that paresthesias in Iesions of the cord tend to be a “single modality of With this patient, before hemorsensation.” rhage and thrombosis this was evident.
REFERENCES
1.
2.
Grinker, R. R., Bucy, P. C., and Sah, A. L.: Neurology, Springfield, Illinois, 1960, Charles C Thomas, Publishers. Guttmacker, A. F., and Rovinsky, J. J.: Medical, surgical and gynecological complications
of pregnancy, Baltimore, Williams & Wilkins Company. Suite 125 W¬ Medical Tucson, Arizona
Bldg. 8571 I
Maryland,
1960,