Pregnancy related symptomatic vertebral hemangioma
A 23-year-old primigravida presented at 28 weeks of gestation with progressive asymmetric weakness of both lower limbs for last 15 days. She also complained of diminished sensation over the lower limbs, along with plaster cast like sensation over the lower limbs and band like feeling at lower chest. She had no back or radicular pain, visual complain, urinary or bowel symptoms. There was no history of trauma, fever, weight loss or anorexia. Past and personal history was non-contributory. General physical examination including the spine was normal. Neurological examination revealed mild spasticity in lower limbs; motor power in left lower limb was Medical Research Council grade 4/5 and in right lower limb was 4/5 except at the ankle dorsiflexors where it was 2/5. Deep tendon reflexes in both lower extremities were brisk, abdominal reflex was absent and had bilateral extensor planter reflex. Sensory examination showed impaired sensation for touch and pain with a sensory level at D10 (spinal segment) and zone of hyperesthesia at D8 spinal segmental level. Posterior column sensations were impaired in both lower limbs and Romberg's sign was positive. Other systemic examination was unremarkable. A working diagnosis of compressive myelopathy (compression at D4-5 vertebral level) was considered.\nComplete hemogram, erythrocyte sedimentation rate, coagulation tests, blood glucose, renal and liver function tests were normal. Ultrasound of abdomen revealed 28 weeks single live intrauterine fetus. Magnetic resonance imaging (MRI) of dorsal spine showed marrow signal alteration in D3-D5 vertebral bodies and associated para-vertebral and posterior epidural extension compressing the spinal cord. Any osseous destruction or collapse of the involved vertebrae was not evident. The MRI findings were consistent with vertebral hemangioma with paravertebral-epidural component [Figure , and ].\nPatient was advised for surgery; however, she declined for it. When her weakness further worsened over next 3 weeks leading to paraplegia and bladder disturbance, she agreed for the surgery. Although the lesion was confined to three vertebrae, the epidural component was relatively more extensive, hence extended laminectomy at D1-5 vertebrae and tumor decompression was done. Histopathology of tumor tissue was also suggestive of hemangioma []. Post-operative ultrasonography showed 32 weeks live intrauterine fetus. There was significant improvement in motor deficit after a week of surgery and she was able to stand with support. Four weeks post-operatively she was able to walk with minimal assistance and also regained normal urinary bladder function. Six weeks postoperatively she delivered a full term normal baby by elective lower segment caesarean section. After delivery there was further clinical improvement and at 3 months follow-up she had minimal residual deficit with brisk deep tendon reflexes in lower limbs and normal sensory examination. Repeat MRI of dorsal spine at 3 months postoperatively showed reduced epidural component of vertebral hemangioma [Figure and ].