A 20-year-old male diagnosed in September 2003 with pre-B intrathecal acute lymphoblastic leukemia underwent intravenous induction chemotherapy and prophylactic chemotherapy with PL.
After applying several treatment schemes for 8 months, there was no complete remission of the disease.
During this time period, 4 lumbar punctures were performed to administer intrathecal chemoprophylaxis without complications.
Repeated CSF analysis was normal in all cases.
Platelet counts prior to these punctures were 34,000, 118,000, 338,000 and 161,000 platelets/mm3 positive.
Prothrombin time (PT) and activated partial thromboplastin time (APTT) were normal and platelet transfusion prior to LP was not performed in any case.
In May 2004, the patient returned to the hospital for a new cycle of chemotherapy and subsequently scheduled a bone marrow transplant.
A new LP was performed without incidents, but at this time several platelet concentrates had to be transfused before carrying the patient a thrombocytopenia of 26,000/mm3.
In the previous 2 months, she had also required several transfusions due to the progressive tendency to thrombocytopenia (below 20,000/mm3).
PT and APTT were normal.
A few hours after LP, the patient required attention for isolated right sciatica.
After 48 hours, radicular pain was associated with loss of strength in both lower limbs, which quickly became bilateral paraparesis, preserving only partial motor strength (3/5) in the foot.
No changes in sensitivity or sphincters were observed.
An emergency thoracolumbar MRI showed an image suggestive of an extraparenchymal intradural ventral hematoma compressing the medullary cone and horsetail from D12 to L4.
After intravenous gadolinium administration, no contrast uptake suggestive of underlying lesion was observed.
Subsequently, a laminectomy was performed between L1 and L4 and a longitudinal durotomy, after which the large-tension horsetail contained in the intact arachnoid membrane was observed.
A small amount of subarachnoid blood clot dorsally compressed the medullary cone.
Examination of the lateral zones showed the presence of a large ventral hematoma also contained in the arachnoid membrane.
A longitudinal incision of the arachnoids was then performed and after separating the dorsal roots of the horsetail, clot was removed.
It was only possible to obtain a subtotal removal of the nerve, since it was partially organized and adhered to the nerve roots.
There were no macroscopic lesions that could be the origin of the hematoma.
The surgical procedure was completed with the closure of the dural plane using a lyophilized plasty to expand space.
The postoperative course was uneventful.
The patient with progressive loss of bone marrow, able to walk on the fourth day, without alterations and continued to develop radicular pain and finally referred only a slight residual shortening in the lower limbs.
Postoperative lumbar MRI could not be performed due to the poor clinical status of the patient.
