Freiburg Neuropathology Case Conference: a Hemorrhagic Intraspinal Tumor Extending from L3 to S1

Excerpt

A 58-year-old male presented to the emergency department with severe back pain. He had fallen on his hip the same day. He immediately experienced severe back pain which was not apparent before. He reported a history of impaired bladder control and fecal incontinence for more than 1 year. Due to pre-existing mental retardation the patient could not give reliable information concerning esthesia but seemed to feel pain proximal to his knees but not his feet. He suffered severe paresis of the psoas muscles and the quadriceps muscles (grade 2/5 both sides) and a complete paralysis of the distal leg muscles. Computed tomography (CT) and magnetic resonance imaging (MRI) were done the same day and revealed an intraspinal mass extending from L3 to S1. Due to the high-grade neurological deficits an emergency open biopsy was performed. After a medial skin incision, a right-sided interlaminar fenestration was performed including a resection of the L2/3 facet joint. After removal of the ligamentum flavum the dura was found to be under pressure from livid material compatible with a hematoma. There was no epidural hematoma. After longitudinal incision of the dura reddish tumor material with high bleeding tendency was found and removed for histopathological examination. It was not possible to delimit the fascicles of the cauda equina within the mass lesion. Preliminary histopathological examination only revealed signs of hematoma within the specimens that had been sent to pathology. Therefore, further epidural preparation to the anterior spinal canal was performed, where more tumor material with epidural compression of the dura was found. Here the preliminary histopathological examination revealed a metastasis or a plasmacytoma as most likely diagnoses. Therefore, no further resection was performed and closure of the approach was performed in layers. Postoperatively the patient showed gradual worsening of the paresis with nearly complete paralysis now also of the quadriceps and the psoas bilaterally (grade 1/5). Postoperative MRI showed signs of a circumscribed decompression at the L2/3 level on the right side and no signs of a new intraspinal bleeding. With respect to the tumor, no possibilities could be seen for further decompression or resection due to the massive hemorrhage and the high vascularization of the tumor tissue. Concerning the instability of the lower lumbar spine and the lumbosacral junction including S1, however, a stabilization was indicated and performed 3 days after the biopsy. Postoperatively the patient showed no additional deficits and during the following days no wound healing problems occurred and he reported an improvement of the sensitivity while the paresis remained stable. …