Teaching NeuroImage: Extramedullary Hematopoiesis Leading to Spinal Cord Compression

A 70-year-old man with myelodysplastic syndrome currently undergoing erythropoiesis stimulation therapy with luspatercept presented with worsening bilateral leg weakness and urinary retention. He had bilateral patellar hyperreflexia, but absent Achilles reflexes and plantar responses bilaterally. T-spine MRI was obtained, which showed extensive T2 hyperintense and enhancing soft-tissue masses in the epidural space compressing the spinal cord, suggestive of possible extramedullary hematopoiesis (EMH) (see Figures 1 and 2). He underwent T5-10 laminectomy and biopsy-confirmed EMH. Cord compression from EMH has been reported in patients with thalassemia and should be considered in other patients with myelopathic presentations who are at risk of EMH, including those with hematologic disorders, bacterial and viral infections, solid tumors (e.g., colon and hepatocellular carcinoma), anemia, and metabolic stress.1,2 Patients receiving luspatercept have also been reported to develop EMH.3 On imaging, EMH will typically appear as T1 and T2-hyperintense lesions with unpredictable enhancement patterns.1 Treatment is focused on the underlying suspected cause and surgical decompression if necessary.