Haematomyelia

HAEMATOMYELIA, haematomyelia (from Greek haima- blood and myelos- marrow), bleeding into the spinal cord. Haematomyelia occurs more often in men than in women; it can occur at any age, but is most common between 20 and 40 years. Etiology. In the vast majority of cases, haematomyelia occurs as a result of trauma: falling from a height onto the back, legs, or head, severe contusions, gunshot wounds to the spine, etc. Furthermore, haematomyelia can result from excessive muscle strain (lifting heavy weights, bending of the spine), strong electric current, lightning strike. General hemorrhagic diathesis, severe infections (typhoid, sepsis), tetanus and other diseases accompanied by convulsions are also noted among the causes of haematomyelia. Small hemorrhages in the substance of the spinal cord are sometimes found in acute myelitis and in brain tumors. Similar haematomyelias are found in the spinal cord of hanged persons and in children born asphyxiated. Among the causes of haematomyelia, however, rather predisposing than producing, are indicated: alcohol, cessation of habitual hemorrhoidal bleeding, interruption of menstruation, sexual excesses, and general arteriosclerosis. Pathological anatomy. Haematomyelia occurs in the form of small (capillary) hemorrhages and hemorrhagic nests. Small hemorrhages are observed both in the white and gray matter of the brain. In more extensive hemorrhages (hemorrhagic nests), sometimes a whole blood clot is observed, shining through the thinned peripheral layer of the brain in the form of a dark swelling, the size of a bean. If the blood has poured into the center of the spinal cord, such haematomyelia is called central, and the hemorrhage can involve both gray and white matter; in other cases, there is hemorrhage only in the gray matter (more often in the posterior horn). The greater frequency of finding haematomyelia in the gray matter is explained by its greater vascularity. Sometimes HAEMATOMYELIA the hemorrhage has the appearance of a ring (annularis haematomyelia of Minor). In some cases, blood penetrates into the central canal or under the meninges. Haematomyelia can be at any level of the spinal cord, but is much more often observed in the cervical enlargement. In the longitudinal direction, small, scattered hemorrhages usually occupy a small extent; conversely, larger, central hemorrhages extend along several segments and even along the entire length of the spinal cord (tubular haematomyelia). In fresh cases, the poured-out blood is liquid; subsequently, it changes in color, is absorbed, and at the site of the hemorrhage, glial proliferation, an apoplectic cyst with glial walls appears. Around the hemorrhage, altered nerve cells and fibers, granular balls are found, and in older cases - glial proliferation. Sometimes haematomyelia, due to secondary glial proliferation, has a progressive course. Due to the destruction of certain areas of the spinal cord, ascending and descending degeneration of the corresponding brain bundles may occur. Symptoms of the disease. Small hemorrhages into the spinal cord have no clinical significance and usually remain unrecognized. Larger hemorrhages, usually occurring after trauma, are characterized by the sudden appearance of paralysis and sensory disturbances. These phenomena increase in intensity over several minutes. There are, however, cases when the attacks of the disease develop over several hours. Often at the very beginning of the disease, severe pains in the spine appear. The clinical picture of the disease is extremely diverse, depending on the size of the hemorrhage and its location. If the hemorrhage occupies almost the entire cross-section of the spinal cord, then there are symptoms characteristic of diffuse transverse myelitis: paralysis, sensory disturbances, disturbance of the function of pelvic organs, trophic and vasomotor disorders. If the hemorrhage affects one side of the spinal cord, then the picture of Brown-Séquard paralysis is observed. Since haematomyelia most often occurs in the gray matter, in the area of the posterior horns, loss of thermal and pain sensitivity is observed. If the hemorrhage also involves the anterior horn, then to the sensory disturbance are added atrophic paralysis of the muscles of the corresponding areas. Sometimes the hemorrhage is located only in the anterior horns of the spinal cord, and then there is a picture of the disease similar to poliomyelitis. When the cervical part of the spinal cord is affected, pupillary symptoms may be observed. The state of reflexes varies depending on the location of the hemorrhage. Reflexes of the lower limbs that disappeared in the first days are quickly restored (of course, if the hemorrhage is not in the lumbar enlargement) and soon even intensify. The temperature in haematomyelia is usually normal, but after several days, due to secondary inflammation, it sometimes rises. Course and outcome of the disease. In cases where the nuclei of the phrenic nerve are affected by the hemorrhage, death occurs quickly, within a few hours. The paralysis and sensory disturbances that appeared initially persist unchanged for 7-10 days, and then begin to slowly decrease, in direct proportion to the fact that the nerve elements are gradually freed from the pressure of blood due to its absorption. The nerve elements destroyed by blood are not restored, and a number of irreparable disorders remain for life. Complete recovery is extremely rare. The life of the patient may also be threatened by bedsores and cystitis. Diagnosis. In exceptional cases, haematomyelia can be confused with acute myelitis, but the latter differs in that it never develops suddenly. Meningeal hemorrhage can be excluded by the absence of significant phenomena of irritation of the nerve roots of the spinal cord, severe pain in the spine, and very strong tension of the spinal muscles. From syringomyelia and gliomatosis, haematomyelia in the chronic stage differs little in the picture of symptoms, but anamnestic data and the progressive course characteristic of syringomyelia make it possible to exclude the latter. Progressive course of haematomyelia occurs in the case of an accompanying secondary gliomatosis. Treatment. In the first days of the disease - complete rest, cold on the back, hemostatic agents; sometimes bloodletting can be resorted to; in addition, it is necessary to carefully observe the bladder and take care to prevent bedsores. After three to four weeks, baths, massage, galvanization and iontophoresis of the spine, preparations of iodine are prescribed.