Case Diagnosis: Intradural extramedullary spinal cord tumor
Case Description: 49-year-old African American female with a past medical history of hypertension and obesity was referred for progressively worsening lower back pain over the past year. Pain radiated to bilateral knees and was associated with occasional numbness and tingling of the lower extremities. She denied bowel or bladder dysfunction. Physical exam was significant for 4/5 strength in left hip flexion, and positive straight leg raises bilaterally. X-Ray lumbosacral spine was unremarkable. There was no improvement with Physical therapy. MRI lumbosacral spine without contrast revealed a large irregular intradural extramedullary tumor at L3 and L4 with mass effect on the cauda equina, suggestive of myxopapillary ependymoma. Follow-up MRI brain and total spine with and without contrast did not reveal any additional tumors or metastasis. She was evaluated by neurosurgical team and scheduled for removal of the tumor.
Discussions: Spinal cord tumors are rare but serious causes of back pain, accounting for less than 1% of all causes of back pain in the primary care setting, with the median time to diagnosis of 12 months. They are classified as extradural (50-55%), intradural extramedullary (40%), and intradural intramedullary (5%). Depending on location they may mimic other causes of back pain, producing various pain and neurological syndromes. Diagnostic imaging, including MRI, should be considered at an early stage especially in cases of back pain with “red flags,” including acute neurological symptoms. Further suspicion for non-mechanical causes of pain should arise with failure to improve with conservative measures, as with our patient. The preferred treatment includes surgical resection after excluding metastasis.
Conclusions: Intradural extramedullary spinal cord tumors are a rare but serious cause of back pain. High index of suspicion including consideration of non-degenerative causes of back pain may lead to early diagnosis and timely management.