Case 9: spinal mass

posted: October 6, 1996

Resident: John Ratliff, MD
Attending: Michael Carey, MD

CLINICAL PRESENTATION: 74 year old white man presented to the ER with the chief complaint of acute onset of severe lower back pain (sharp and stabbing) while eating breakfast the morning of his presentation. Mild lower extremity weakness was also noted with the onset of lower back pain. The patient had noted a similar episode of lower back pain, without weakness, three weeks previously. This pain resolved completely after a 4 hour period of bedrest. After the onset of the current pain, patient took a 5mg valium tablet and went to bed. When he awke 3 hours later, he was unable to move his legs. The EMS was contacted and the patient was taken to the ER.

Past medical history is significant for hypertensin (treated with Procardia), TIA's (treated with aspirin), Parkinson's disease (on Sinemet).

Neurological examination was significant for a sensory level (to light touch and pinprick) at roughly L2. Vibratory sensation was absent, but position sensation present in both lower extremities. Motor strenght was 0 of 5 in all groups tested in the lower extremities. There was absent rectal tone, absent cremaster and bulbocavernous reflexes, absent deep tendon reflexes (generalized). No clonus and no pathological reflexes. After Foley catheter insertion, 800cc residual urine was withdrawn.

The patient was taken emergently for a lumbo-thoracic MRI scan thinking of a mass lesion in the spinal canal compressing the thecal sac near thoracolumbar junction.

DIAGNOSTIC STUDIES: Thoracolumbar MRI scan (with and without contrast). Below are select films from the thoracolumbar area.

Multiple images (T2 on the left, mixed density in center and T1 on the right) reveal an epidural mass (red marker) extending from about T10 to L1. It has a mixed signal.

Axial T1WI (with contrast) showing the epidural mass at T11-12 (red marker)

What is your differential diagnosis?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: The patient was emergently taken to the OR where a T10-L2 laminectomy was performed. A spinal epidural hematoma was found at exploration and successfully evacuated with decompression of the thecal sac. No pathologic findings were noted upon microscopic examination of the hematoma mass.

POSTOPERATIVE COURSE: The patient made slow, but, good recovery of lower extremity function and mild-moderate recovery of bladder function. The patient was ambulating with assistance on postop day 5, and was fully ambulatory by discharge (about 2.5 weeks postop). He is currently in an out-patient rehab program.

Return to Grand Rounds Page