1. Kristen McCormick, DO1; Priya Mhatre, MD1,2, Nicole Wysocki, MD1,2
Spinal Cord Injury & Compression Fracture caused by Hemangioma in a Pregnant Woman: A Case Report
Kristen McCormick, DO1; Priya Mhatre, MD1,2, Nicole Wysocki, MD1,2
1Rehabilitation Institute of Chicago, Chicago, Illinois ; 2Northwestern University / Feinberg School of Medicine, Chicago, Illinois
Case Diagnosis
Imaging
Discussion
Hemangioma within the body of the T11 vertebrae, causing cord compression and incomplete spinal cord injury in a woman in the peripartum period.
Pre-Operative MRI
Post-Operative Imaging
[A] Sagittal T2 MRI showing retropulsion of the fracture fragments and extensive epidural tumor hemangioma causing severe spinal canal stenosis and cord compression at T11. There is hyperintensity within the spinal cord extending from T10-12 with cord edema related to compression. [B] Axial T2 MRI at the T11 level showing extension of the tumor into the spinal canal causing significant cord compression. A B C D E
[C] Post-operative sagittal T2 MRI with residual hemangioma within the spinal canal and cord compression, though slightly improved when compared to pre-op MRI. [D & E] X-Rays (AP & lateral, respectively) of the T-spine at 6-month follow up, showing hardware in good alignment and stable posterior subluxation of the T11 graft within the cord canal.
Vertebral hemangiomas are the most common benign tumor of the spinal column, being present in up to 12% of the population, with women more affected than men [1]. Of all hemangiomas, < 1% become symptomatic. Pregnancy is well known for triggering otherwise asymptomatic hemangiomas to become “aggressive”, or symptomatic, particularly in the third trimester and in the postpartum period. Physiologic factors including increased blood volume, increased vascular congestion, and increased circulating levels of progesterone & estrogen all play key roles in hemangioma growth and risk of neurologic compromise [2, 3]. Typically, these patients complain of an aching low back pain, complicating the diagnosis, as research has shown that up to 45% of postpartum women complain of back pain in the week after delivery [4]. A thorough neurologic exam is key is in identifying these high-risk patients, with urgent referral for possible neurosurgical intervention. Literature search reveals less than 30 reported cases of symptomatic vertebral hemangiomas leading to cord compression in the peripartum patient. No reported cases discuss functional recovery through intensive inpatient or outpatient rehabilitation. In our case, the patient was able to make significant functional recovery through intensive inpatient therapy, with gradual transition to the outpatient setting. Psychology and support services were critical in her care, assisting in the management of separation anxiety from her infant, and providing emotional support throughout her recovery.
Case Description
Prior to Inpatient Rehabilitation
Patient presented out the outpatient women’s health rehabilitation clinic for insidious onset of low back and hip pain at 29 weeks gestation. She began PT for core & pelvic strengthening, posture and mechanics of the entire spine. She began noting upper spine pain and soreness at 37 weeks gestation, but had no neurologic deficits at that time. She delivered via C-section at 41 weeks gestation after prolonged attempted vaginal labor. She continued to have low back pain after discharge from delivery, following up in the clinic 12 days post-partum with no neurologic deficits or bowel/bladder changes. PT was continued as previously ordered. At her 6 week follow up, patient complained of gait instability with leg “heaviness”. Physical exam showed 3/5 strength in bilateral hip flexors, 4/5 strength in hip abduction & knee extension, with new-onset of clonus in the left ankle. MRI was ordered of the lumbar spine, showing a pathologic compression fracture of the T11 vertebral body due to a hemangioma with retropulsion of ossific fragments into the spinal canal causing severe spinal stenosis and cord compression. She underwent T10-11 laminectomies and T9-L1 posterior spinal fusion, followed by IR embolization of the T11 hemangioma with coils and onyx liquid embolic agent, then T11 corpectomy and cage placement for ventral spinal cord decompression. She required minimal assistance ambulating 15’ using a rolling walker, moderate assistance in bed mobility & transfers, and maximal assistance with upper & lower body dressing at the time of discharge from the acute care hospital to acute inpatient rehabilitation (AIR).
Conclusion
Individuals with spinal hemangioma are at risk for pathologic vertebral fracture and spinal cord compression in the peripartum period. These patients benefit from acute inpatient rehabilitation in a center specialized in spinal cord injury. Treatment should be based on patient goals and functional status upon admission. Outpatient therapy after discharge from inpatient care will optimize outcomes and improve independence in the home and community setting. Post-partum patients require special attention in regards to emotional state and functional goals associated with infant care.
Rehabilitation Phase
The patient participated in 3 weeks of AIR, followed by 7 months of Day Rehabilitation (consisting of rigorous 5-day/week coordinated outpatient PT & OT). She then began bi-weekly outpatient PT, which is currently ongoing.
References
 1. Jain, R.S., et al., Aggressive vertebral hemangioma in the postpartum period: an eye-opener. Oxf Med Case Reports, (7): p
2. Nelson, D.A., Spinal Cord Compression Due to Vertebral Angiomas during Pregnancy. Arch Neurol, : p
3. Tekkok, I.H., et al., Vertebral hemangioma symptomatic during pregnancy--report of a case and review of the literature. Neurosurgery, (2): p ; discussion 306.
4. Russell, R. and F. Reynolds, Back pain, pregnancy, and childbirth. BMJ, (7087): p
Functional Independence Measures (FIM) scores at various points throughout rehabilitation, where 0 = activity doesn’t occur, 1=Total assist, 2=Max assist, 3= Mod assist, 4=Min assist, 5=Supervision, 6=Modified independent, 7=Independent. DR = Day Rehabilitation Program
Contact Information:
Kristen T. McCormick, DO | Priya Mhatre, MD | Nicole Wysocki, MD