CASE REPORT: T2 Hyperintense Extradural Lumbar Mass. Clinical Presentation and Outcome.
Dax K. Sirucek, D.C., D.A.C.N.B., F.S.B.T
Abstract: This case report demonstrates the clinical presentation, treatment, and outcome of a patient with a T2 hyperintense extradural mass in the lumbar spine. Review of the patient’s medical history, intake, radiographic reports, clinical examination, and lumbar MRI are reviewed.
Introduction: The patient, a 63-year-old male, presented after suffering an acute lumbar injury while lifting drywall at work. He presented to our clinic as a workers compensation injury.
On intake the patient rated his lumbar pain as an 8/10 on a 1-10 pain scale. He reported his pain as constant and traveling down the posterior portion of his thighs bilaterally. Prior to this injury his lumbalgia was rated as a 3-5/10 which occasionally traveled down his thighs bilaterally during times of exacerbation. He referred to his pain prior to this exacerbation as arthritic and due to old age. The patient denied any radiating pain, weakness, or numbness below his knees. The pain was reduced with Ibuprofen. The patient reports taking 6-8 Ibuprofen per day and recognizes that this is not healthy but states that it does help with his pain. The patient’s lower back pain is worse with lifting, sitting, coughing, sneezing, and bowel movements. The pain is described as achy and shooting from his lower back down the back of his thighs bilaterally.
Past medical history: The patient has worked as a handy man for a commercial HVAC and plumbing company for approximately seven years. He reports having aches and pains all over and states that he has osteoarthritis in all his joints. He has not undergone any prior surgeries. He has a history of high blood pressure, heart attack, and believes he may have had a minor stroke in his past, but imaging at the emergency room was negative and he feels he fully recouped. Overall, he states that he has been feeling good lately and hasn’t had any complaints recently until he hurt is lower back.
Clinical Findings: The patient is a 63-year-old male. He is 5’8” tall and weighs 237 pounds. Blood pressure was 166/126 mmHg, heart rate was 71 BPM, and oxygen saturation was 97%. There was slight swelling in the ankles and feet bilaterally. Cranial nerves were intact and exhibited normal function. The patient was in an antalgic flexed posture. Examination consisted of AP and lateral lumbar radiographs. Orthopedic and neurological examination. Cardiovascular health was discussed with the patient and an appointment was set with a cardiologist for examination.
AP and lateral lumbar radiographs revealed mild to moderate spondylosis and a slight convex curvature. The radiographs were negative for ligament laxity, listhesis, and blastic/lytic lesions.
Physical findings: With palpation there was moderately severe pain bilaterally from S1-L1. All ranges of motion were severely restricted with extension causing the most pain. Valsava’s test was positive for local lower back pain. Kemp’s test was positive for local lumbar pain, but the patient did not report any increase in pain or weakness in his legs. Nachlas’, Yeoman’s, Hibb’s, and straight leg raise tests were positive bilaterally. No radicular pain was reported during these orthopedic tests and the posterior thigh pain was not exacerbated.
Neurological examination: Lower extremity reflexes were graded as 1+/5 bilaterally. Sensory testing was found to be reduced (hypoesthesia) bilaterally in the feet across all dermatomes. Muscle strength testing revealed 4/5 hip flexion bilaterally, 5/5 leg extension bilaterally, 5/5 leg flexion bilaterally, 5/5 toe walk bilaterally, and 4/5 heel walk bilaterally. There were no signs of flexor reflex afferent activity during Babinski’s testing. Pathologic reflexes were considered normal.
Treatment: Considering the above findings the patient was recommended to get a lumbar MRI. However, he had a large deductible and was not able to cover the out-of-pocket costs. The patient’s employer was contesting the injury as being work related. Therefore, no imaging other than lumbar radiographs were obtained initially. Conservative chiropractic care was provided at a frequency of two visits per week. Although improvement was slow, after a period of 30 days pain had reduced and neurologic symptoms improved but did not fully resolve. The patient felt he had better strength in his thighs when getting in and out of his car and going up stairs. Heel walk improved, and he returned to full duty at work.
While at work approximately one month later the patient slipped and fell on his buttocks and left hip. Conservative chiropractic care was provided again on basis of two visits per week. After two weeks the patient had returned to pre-injury status and again returned to full work duties.
Approximately two weeks after the slip and fall the patient had another acute, non-traumatic onset of lower back pain. Upon examination it was evident that the prior neurologic symptoms had returned. A lumbar MRI was ordered. The MRI findings are reviewed below.
Image 1: A mid sagittal slice reveals a large T2 enhancing extradural mass measuring 2.3 cm transverse and 3.5 cm craniocaudad from the top of L2 to the top of L3. The mass is displacing and compression the cauda equina causing severe central stenosis. It is thought initially to be metastatic disease or an atypical meningioma or schwannoma.
Image 2: Left parsagittal view of the mass at L2 extending into the paraspinal musculature.
Image 3: An axial view at the level of the L2 vertebral body shows severe central stenosis. It is also seen that the left L2 lamina may be involved as the enhancing tissue is seen extending into the left paraspinal musculature.
Image 4: Disc bulging and desiccation with severe foraminal stenosis.
Image 5: This slice of this MRI was not through the plane of the intervertebral disc; however, it is evident that there is a disc osteophyte complex causing moderate right and severe left neuroforaminal stenosis.
Treatment: The patient underwent surgery to relive neurologic compression and remove the spinal mass at L2. Post-surgical rehabilitation has gone well and the patient has fully recouped. Sensory and motor function has returned to normal. Conservative post-surgical chiropractic treatment and management is ongoing. Periodic neurologic examinations are performed to assess the patient’s recovery and to continue addressing other areas of stenosis and neurologic compression.
Prognosis: Initially this tumor was thought to be malignant. However, pathology revealed this was not the case. The tissue was described as compressed and fibrotic and suggestive of a cavernous hemangioma. The patient made a full recovery.
Discussion: Chiropractic physicians with advanced training in MRI can help fill the void of non-surgical spine specialists in health care. Not only can they provide a thorough examination and diagnosis but may provide additional treatment options outside the typical medical model of medication and surgery. Chiropractors, especially those with advanced credentialing in MRI should be utilized more readily in the standard health care setting.
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