Abstract
We report the case of a patient with multiple myeloma (MM) and extensive lytic bone disease who presented with a short history of back pain and leg weakness. Magnetic resonance imaging (MRI) of the lumbar spine revealed a sacral insufficiency fracture complicated by an epidural haematoma. Bleeding tendency in this case can be accounted for by platelet function defects, often described in plasma cell disorders in the absence of obvious coagulation abnormalities. Surgical intervention was contraindicated as a result of poor overall patient performance status (poor surgical candidate due to extensive myelomatous bone disease, previous vertebral compression fractures requiring orthopaedic stabilisation, and requiring opiate analgesia for bone pain) and management was conservative. Patients presenting with back pain and documented bone disease in the setting of myeloma should be managed with a high index of clinical suspicion and considered for urgent MR imaging to avoid missing this serious and potentially reversible complication. We report the undescribed causative association between sacral insufficiency fracture and lumbo-sacral epidural haematoma. We illustrate the MRI signal and contrast enhancement pattern of an acute presentation of epidural haematoma.
Similar content being viewed by others
References
Jackson R (1869) Case of spinal apoplexy. Lancet 2:5–6
Holtas S, Heiling M, Lonntoft M (1996) Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology 199:409–413
Lourie H (1982) Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248:715–717
Dasgupta B, Shah N, Brown H, Gordon TE, Tanqueray AB, Mellor JA (1998) Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 37:789–793
Lee K, McWhorter J, Angelo J (1988) Spinal epidural hematoma associated with Paget’s disease. Surg Neurol 30:131–134
David S, Salluzzo RF, Bartfield JM, Dickinson ET (1997) Spontaneous cervicothoracic epidural hematoma following prolonged Valsalva secondary to trumpet playing. Am J Emerg Med 15:73–75
Muhonen M, Piper J, Moore S, Menezes A (1995) Cervical epidural hematoma secondary to an extradural vascular malformation in and infant. Case Report. Neurosurgery 36:585–588
Lovblad KO, Baumgartner RW, Zambaz BD, Remonda L, Ozdoba C, Schroth G (1997) Nontraumatic spinal epidural hematomas. MR features. Acta Radiol 38:8–13
Rothfus W, Chedid M, Deeb Z, abla A, Maroon J, Sherman R (1987) MR imaging in the diagnosis of spontaneous spinal epidural hematomas. J Comput Assist Tomogr 11:851–854
Tarr R, Drolshagen L, Kermer T, Allen J, Partain C, James A (1987) MR imaging of recent spinal trauma. J Comput Assist Tomogr 11:412–417
Fukui MB, Swarnkar AS, Williams RL (1999) Acute spontaneous spinal epidural hematomas. Am J Neuroradiol 20(8):1365–1372
Mascalchi M, Torselli P, Falaschi F, Dal Pozzo G (1995) MRI of spinal epidural lymphoma. Neuroradiology 37:303–307
Chen C, Ro L (1996) Central gadolinium enhancement of an acute spontaneous spinal epidural hematoma. Neuroradiology 38:114–116
Priest WM (1935) Epidural haemorrhage due to haemophilia. Lancet 2:1289–1291
Boukobza M, Guichard JP, Boissonet M, George B, Reizine D, Gelbert F, Merland JJ (1994) Spinal haematoma: report of 11 cases and review of literature. Neuroradiology 36:456–459
Saito S, Katsube H, Kobayashi Y (1994) Spinal epidural hematoma with spontaneous recovery demonstrated by magnetic resonance imaging. Spine 19:483–486
Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VKH, Dickman CA (1995) Surgical management of spinal epidural haematoma: relationship between surgical timing and neurological outcome. J Neurosurg 83:1–7
Duffill J, Sparroe OC, Millar J, Barker CS (2000) Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases. J Neurol Neurosurg Psychiatry 69:816–819
Lee JI, Hong SC, Shin HJ, Eoh W, Byun HS, Kim JH (1996) Traumatic spinal subdural hematoma: rapid resolution after repeated lumbar spinal puncture and drainage. Journal of Trauma 40(4):654–655
Blake SP, Connors AM (2004) Sacral insufficiency fracture. Br J Radiol 77(922):891–896
Butler CL, Given CA, Michel SJ, Tibbs PA (2005) Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol 184(6):1956–1959
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cronin, C.G., Lohan, D.G., Swords, R. et al. Sacral insufficiency fracture complicated by epidural haematoma and cauda equina syndrome in a patient with multiple myeloma. Emerg Radiol 14, 425–430 (2007). https://doi.org/10.1007/s10140-007-0623-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-007-0623-z