Re: A woman with acute myelopathy in pregnancy: case progression
My wife, now aged 56, has always been fit and healthy, walking numerous dogs up to five miles a day and regularly horse riding. In May 2010 she was thrown from her horse and sustained a burst but stable fracture of the body of L4. Hospitalised for about 10 days, she was gradually mobilised and within a year was back to walking her dogs and riding daily. Her admission was complicated by the discovery of an 8cm Ovarian cyst. She required a hysterectomy and bilateral salpingo oophorectomy which was performed uneventfully in October 2010. She was home 36 hours post operatively. All was well until January 2012 when she began to have some low back pain and sensory changes in her lower legs. Fearing she had some nerve compression following her spinal fracture she was referred to a spinal surgeon, who after studying her MRI declared he thought her problem was “more central.” By now her Babinski reflex, which had always been flexor, had changed to extensor bilaterally, her tickle reflex in her feet had gone, both ankle reflexes had gone, and proprioception was severely disturbed She was walking with a stick and could only manage to walk 30 yards.
Next was a referral to a neurologist which involved more MRIs of her brain and whole spine, together with a batch of blood tests and a lumbar puncture. All these tests including lyme serology were negative. The neurologist finally said she clearly had a progressive myelopathy but no evidence of Multiple Sclerosis or of an infection. He did not know what the cause of her myelopathy was and had no treatment to offer.
Coming to terms with a progressive myelopathy was difficult, adaptations were made at home, she began to use a mobility scooter but was unable to show her beloved dogs. The future for her seemed grim. I had fully retired to look after her.
On the 14th October this year she collapsed with a sudden episode of pleuritic chest pain which turned out to multiple pulmonary emboli. She was again admitted to hospital and required oxygen for 5 days, running significantly hypoxic without it. A CTPA confirmed bilateral pulmonary emboli. There was no clinical evidence of a DVT. The day after admission, when trying to get to a toilet she remarked my legs are different “ I know where my feet are”. She was fully anticoagulated and eventually allowed home to recover.
Since being at home for the last two weeks all the neurological signs have gone and she seems neurologically normal. This was confirmed by a visit to another consultant neurologist. Her walking is only limited by residual breathlessness from her PE and can already manage more than 500 yards
I can only surmise that her myelopathy was due to vascular impairment of her lumbar spine caused by a blood clot in a vein draining her spine. This was the source of the blood clot which shifted to her lungs. I have been unable to find any reports of a similar situation. I wonder if a D dimer test should be considered as an investigation for unexplained myelopathies? I am delighted to find my wife can walk normally again and anticoagulation is a very small price to pay for her mobility. She will not be horse riding again.
My wife has a very large number of friends in the international dog world, a great many of whom wrote to her offering support, their prayers and white light that she would recover fully. Her recovery seems quite miraculous. These prayers were most effective!
My wife fully consents to the publication of this case report
Dr K Hines MRCGP
Competing interests:
No competing interests
08 November 2012
Kenneth C Hines
recently retired GP
N/A
Redroof Farm, Bye Lane, Brothertoft, Near Boston Lincolnshire PE20 3SE
Rapid Response:
Re: A woman with acute myelopathy in pregnancy: case progression
My wife, now aged 56, has always been fit and healthy, walking numerous dogs up to five miles a day and regularly horse riding. In May 2010 she was thrown from her horse and sustained a burst but stable fracture of the body of L4. Hospitalised for about 10 days, she was gradually mobilised and within a year was back to walking her dogs and riding daily. Her admission was complicated by the discovery of an 8cm Ovarian cyst. She required a hysterectomy and bilateral salpingo oophorectomy which was performed uneventfully in October 2010. She was home 36 hours post operatively. All was well until January 2012 when she began to have some low back pain and sensory changes in her lower legs. Fearing she had some nerve compression following her spinal fracture she was referred to a spinal surgeon, who after studying her MRI declared he thought her problem was “more central.” By now her Babinski reflex, which had always been flexor, had changed to extensor bilaterally, her tickle reflex in her feet had gone, both ankle reflexes had gone, and proprioception was severely disturbed She was walking with a stick and could only manage to walk 30 yards.
Next was a referral to a neurologist which involved more MRIs of her brain and whole spine, together with a batch of blood tests and a lumbar puncture. All these tests including lyme serology were negative. The neurologist finally said she clearly had a progressive myelopathy but no evidence of Multiple Sclerosis or of an infection. He did not know what the cause of her myelopathy was and had no treatment to offer.
Coming to terms with a progressive myelopathy was difficult, adaptations were made at home, she began to use a mobility scooter but was unable to show her beloved dogs. The future for her seemed grim. I had fully retired to look after her.
On the 14th October this year she collapsed with a sudden episode of pleuritic chest pain which turned out to multiple pulmonary emboli. She was again admitted to hospital and required oxygen for 5 days, running significantly hypoxic without it. A CTPA confirmed bilateral pulmonary emboli. There was no clinical evidence of a DVT. The day after admission, when trying to get to a toilet she remarked my legs are different “ I know where my feet are”. She was fully anticoagulated and eventually allowed home to recover.
Since being at home for the last two weeks all the neurological signs have gone and she seems neurologically normal. This was confirmed by a visit to another consultant neurologist. Her walking is only limited by residual breathlessness from her PE and can already manage more than 500 yards
I can only surmise that her myelopathy was due to vascular impairment of her lumbar spine caused by a blood clot in a vein draining her spine. This was the source of the blood clot which shifted to her lungs. I have been unable to find any reports of a similar situation. I wonder if a D dimer test should be considered as an investigation for unexplained myelopathies? I am delighted to find my wife can walk normally again and anticoagulation is a very small price to pay for her mobility. She will not be horse riding again.
My wife has a very large number of friends in the international dog world, a great many of whom wrote to her offering support, their prayers and white light that she would recover fully. Her recovery seems quite miraculous. These prayers were most effective!
My wife fully consents to the publication of this case report
Dr K Hines MRCGP
Competing interests: No competing interests