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Pagano A, Iaquinandi A, Fraioli MF, Bossone G, Carra N, Salvati M. Cauda equina syndrome from intradural metastasis of a non-neural tumor: case report and review of literature. Br J Neurosurg 2023; 37:1487-1494. [PMID: 34330176 DOI: 10.1080/02688697.2021.1958155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cauda equina syndrome (CES) is a challenging condition and it can be caused by variable entities. Leptomeningeal carcinomatosis (LC) is a multifocal seeding of the leptomeninges by malignant cells and it is observed in 1-8% of patients with solid tumors. Diagnosis of intradural metastases of the cauda equina is often delayed due to the non-specific characteristics of this condition but also to the delay of presentation of many patients. Cauda equina metastases usually occur in advanced cancers, but rarely can be the first presentation of disease. CASE DESCRIPTION A 63-year-old man presented with 6 months history of low back pain and 20 d history of bilateral sciatica, hypoesthesia of the legs and the saddle, flaccid paraparesis and bowel incontinence determine by multiple nodular small lesions on the entire cauda equina with contrast-enhancement. Total-body CT showed a millimetric lesion at the lung. The patient underwent L2-L5 laminectomy and subtotal removal and histological examination showed a small cell lung carcinoma metastasis. CONCLUSIONS In the literature, 54 cases of CES from non-CNS tumor metastasis are described. The diagnosis is challenging, back pain, with or without irradiation to the lower limbs, is the most frequently reported disturbance. In about 30% of patients there is no known malignancy and CES is the first clinical presentation. Treatment of choice is surgery, followed by radiotherapy and less frequently adjuvant chemotherapy. The surgical removal is almost always incomplete and functional outcome is often not satisfactory. Prognosis is poor.
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Affiliation(s)
- Andrea Pagano
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | - Andrea Iaquinandi
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | - Mario Francesco Fraioli
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
| | | | | | - Murizio Salvati
- Department of Neurosurgery, Policlinico 'Tor Vergata', University of Rome 'Tor Vergata', Rome, Italy
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Abstract
Though metastasis and malignant infiltration of the peripheral nervous system is relatively rare, physicians should have a familiarity with their presentations to allow for prompt diagnosis and initiation of treatment. This article will review the clinical presentations, diagnostic evaluation, and treatment of neoplastic involvement of the cranial nerves, nerve roots, peripheral nerves, and muscle. Due to the proximity of the neural structure traversing the skull base, metastasis to this region results in distinctive syndromes, most often associated with breast, lung, and prostate cancer. Metastatic involvement of the nerve roots is uncommon, apart from leptomeningeal carcinomatosis and bony metastasis with resultant nerve root damage, and is characterized by significant pain, weakness, and numbness of an extremity. Neoplasms may metastasize or infiltrate the brachial and lumbosacral plexuses resulting in progressive and painful sensory and motor deficits. Differentiating neoplastic involvement from radiation-induced injury is of paramount importance as it dictates treatment and prognosis. Neurolymphomatosis, due to malignant lymphocytic infiltration of the cranial nerves, nerve roots, plexuses, and peripheral nerves, deserves special attention given its myriad presentations, often mimicking acquired demyelinating neuropathies.
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Intradural Metastasis from Cutaneous Squamous Cell Carcinoma Causing Cauda Equina Syndrome. Can J Neurol Sci 2019. [DOI: 10.1017/cjn.2019.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Capek S, Howe BM, Amrami KK, Spinner RJ. Perineural spread of pelvic malignancies to the lumbosacral plexus and beyond: clinical and imaging patterns. Neurosurg Focus 2015; 39:E14. [DOI: 10.3171/2015.7.focus15209] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Perineural spread along pelvic autonomie nerves has emerged as a logical, anatomical explanation for selected cases of neoplastic lumbosacral plexopathy (LSP) in patients with prostate, bladder, rectal, and cervical cancer. The authors wondered whether common radiological and clinical patterns shared by various types of pelvic cancer exist.
METHODS
The authors retrospectively reviewed their institutional series of 17 cases concluded as perineural tumor spread. All available history, physical examination, electrodiagnostic studies, biopsy data and imaging studies, evidence of other metastatic disease, and follow-up were recorded in detail. The series was divided into 2 groups: cases with neoplastic lumbosacral plexopathy confirmed by biopsy (Group A) and cases included based on imaging characteristics despite the lack of biopsy or negative biopsy results (Group B).
RESULTS
Group A comprised 10 patients (mean age 69 years); 9 patients were symptomatic and 1 was asymptomatic. The L5–S1 spinal nerves and sciatic nerve were most frequently involved. Three patients had intradural extension. Seven patients were alive at last follow-up. Group B consisted of 7 patients (mean age 64 years); 4 patients were symptomatic, 2 were asymptomatic, and 1 had only imaging available. The L5–S1 spinal nerves and the sciatic nerve were most frequently involved. No patients had intradural extension. Four patients were alive at last follow-up.
CONCLUSIONS
The authors provide a unifying theory to explain lumbosacral plexopathy in select cases of various pelvic neoplasms. The tumor cells can use splanchnic nerves as conduits and spread from the end organ to the lumbosacral plexus. Tumor can continue to spread along osseous and muscle nerve branches, resulting in muscle and bone “metastases.” Radiological studies show a reproducible, although nonspecific pattern, and the same applies to clinical presentation.
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Affiliation(s)
- Stepan Capek
- Departments of 1Neurosurgery and
- 22nd Faculty of Medicine, Charles University in Prague, Czech Republic
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Perineural spread of squamous cell carcinoma: From skin to skin through the brachial plexus. Clin Neurol Neurosurg 2015; 128:90-3. [DOI: 10.1016/j.clineuro.2014.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 11/09/2014] [Indexed: 11/22/2022]
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Intradural cauda equina metastasis of renal cell carcinoma: a case report with literature review of 10 cases. Spine (Phila Pa 1976) 2013; 38:E1171-4. [PMID: 23759799 DOI: 10.1097/brs.0b013e31829cef66] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report with literature review. OBJECTIVE To describe a rare case of intradural spinal metastasis from renal cell carcinoma (RCC) spread to the cauda equina, and to discuss the clinical features of metastatic RCC in the cauda equina from the data available in the literature. SUMMARY OF BACKGROUND DATA Intradural spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a RCC to the cauda equina is extremely rare with previously only 9 case reports. METHODS A 68-year-old male presented with a 2-month history of worsening lower back pain radiating to both legs. The patient had undergone nephrectomy for the treatment of the clear cell RCC 16 years before admission. Magnetic resonance imaging showed a well-defined intradural extramedullary mass in the cauda equina at T12 to L1. RESULTS The pathological examination displayed metastatic clear cell RCC. Additional imaging studies showed no metastatic in other locations. The patient was discharged without neurological deficit and pain after the operation, and maintained an optimal condition for 2 years. CONCLUSION When a lesion of the cauda equina presents, intradural metastasis should be in the differential diagnosis in patients who had been previously treated for RCC although any other metastatic lesion was not observed. LEVEL OF EVIDENCE N/A.
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Anal cancer with cerebral metastasis: a case report. J Neurooncol 2010; 101:141-3. [PMID: 20440537 DOI: 10.1007/s11060-010-0218-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2010] [Accepted: 04/19/2010] [Indexed: 12/12/2022]
Abstract
Carcinoma of the anal canal is a relatively rare cancer with a low propensity for metastasis. A literature review identifies two cases of brain metastases from anal cancer. The authors present the case of a 63-year-old female with poorly differentiated squamous cell carcinoma of the anal canal who presented with a solitary dural-based enhancing lesion of the right parietal area. The patient underwent craniectomy and tumor resection. Histopathology confirmed the cerebral lesion to be a poorly differentiated squamous cell carcinoma, consistent with the known primary tumor of the anal canal. Although exceptionally rare, the presence of a cerebral lesion in a patient with carcinoma of the anal canal should raise the possibility of metastatic disease. Treatment decisions in patients with newly diagnosed dural-based enhancing lesions and known anal cancer should bear in mind the possibility of metastatic disease.
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Extramedullary-Intradural Spinal Metastasis of Small Cell Lung Cancer Causing Cauda Equina Syndrome. Am J Med Sci 2010; 339:192-4. [DOI: 10.1097/maj.0b013e3181bedd1f] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intradural spinal metastasis to the cauda equina in renal cell carcinoma: a case report and review of the literature. Spine (Phila Pa 1976) 2009; 34:E892-5. [PMID: 19910759 DOI: 10.1097/brs.0b013e3181b34e6c] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case description. OBJECTIVES To describe a case of intradural metastasis from a renal cell carcinoma (RCC) spread to the cauda equina, and review the pertinent medical literature. SUMMARY OF BACKGROUND DATA Intradural spinal metastasis is rare, accounting for 6% of all spinal metastases. Only 7 cases of intradural metastasis from a RCC to the cauda equina have been previously reported. METHODS A 41-year-old male presented with a 1-month history of severe back pain radiating to both legs. The patient underwent a right nephrectomy for treatment of a RCC 1-year before admission. Magnetic resonance imaging showed a well-demarcated, intradural extramedullary mass at the L2 vertebra. RESULTS After a total laminectomy, total excision of the tumor was achieved followed by rapid improvement of the back pain. The tumor was histologically verified as metastatic RCC, identical to that of a previous tumor specimen. The patient was asymptomatic on the 1-year follow-up. CONCLUSION Although the majority of cauda equina tumors are primary tumors, intradural metastasis should be considered before surgery in patients with previously treated RCC.
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Treatment strategies of space-occupying intradural metastases of the cauda equina of nonneurogenic origin. Acta Neurochir (Wien) 2009; 151:207-15. [PMID: 19247571 DOI: 10.1007/s00701-009-0214-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Accepted: 02/07/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Compressive intradural metastases of the cauda equina are a rare site of metastatic spread in systemic cancer. So far, only few reports have been published with conflicting statements concerning a surgical versus nonsurgical approach. METHOD Five patients with symptomatic space-occupying intradural metastases of the cauda equina were analyzed retrospectively, focusing on the influence of surgical intervention on pain relief, neurological outcome and thus the patients' quality of life. FINDINGS At the time of diagnosis, all patients were in an advanced metastatic state. Surgical resection was the primary treatment in four patients and radiotherapy in one. Despite infiltration of the cauda rootlets, gross total tumour resection could be achieved in two of the four patients treated surgically. Functional outcome was beneficial in these patients with marked and immediate relief of pain and improvement of motor function even following incomplete tumour resection. CONCLUSIONS Surgical treatment of compressive intradural metastases of the cauda equina seems to be feasible with low operative risk and with the potential benefit of an immediate relief of pain and improvement in motor function and thus an increase in quality of life.
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Intradural squamous cell carcinoma in the sacrum. World J Surg Oncol 2009; 7:16. [PMID: 19208260 PMCID: PMC2644692 DOI: 10.1186/1477-7819-7-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 02/11/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leptomeningeal carcinomatosis occurs in patients with cancer at the rate of approximately 5%; it develops particularly in patients with breast cancer, lung cancer, melanoma, leukemia, or malignant lymphoma. We describe a rare case of leptomeningeal carcinomatosis in which spinal intradural squamous cell carcinoma with no lesions in the cerebral meninges and leptomeninx, was the primary lesion. METHODS A 64-year-old man complained of sacral pain. Although the patient was treated with analgesics, epidural block and nerve root block, sacral pain persisted. Since acute urinary retention occurred, he was operated on. The patient was diagnosed as having an intradural squamous cell carcinoma of unknown origin. RESULTS Since the patient presented with a slightly decreased level of consciousness 2 months after surgery, he was subjected to MRI scanning of the brain and spinal cord, which revealed disseminated lesions in the medulla oblongata. The patient died of pneumonia and sepsis caused by methicillin-resistant Staphylococcus aureus 5 months after surgery. CONCLUSION We report the first case of a patient with intradural squamous cell carcinoma with unknown origin that developed independently in the sacrum.
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Kotil K, Kilinc BM, Bilge T. Spinal metastasis of occult lung carcinoma causing cauda equina syndrome. J Clin Neurosci 2007; 14:372-5. [PMID: 17336230 DOI: 10.1016/j.jocn.2006.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 01/04/2006] [Accepted: 01/05/2006] [Indexed: 11/29/2022]
Abstract
Cauda equina syndrome (CES) may be caused by tumor, herniated disc, trauma and spinal infections. However, CES due to occult lung cancer has not been reported in the literature. A 50-year-old man presented with a subacute CES caused by an intradural metastasis of an adenocarcinoma of the lung to the lumbosacral cauda fibers. His lumbosacral magnetic resonance imaging (MRI), showed a well-demarcated, intradural extramedullary mass lesion resembling a neurinoma at the L4/5 level. The patient underwent an L4-L5 laminectomy. The operative findings were also suggestive of neurinoma with involvement of three nerve roots, and a well-demarcated tumor without infiltration into the subarachnoid space. Although the findings of the operation were suggestive of neurinoma, final pathological diagnosis revealed metastatic carcinoma. Immunohistochemistry revealed clear cell adenocarcinoma metastasis. Chest X-ray and high resolution contrasted pulmonary computed tomography were normal. Positron emission tomography (PET) showed a lung mass, at the left apex. The patient was treated with chemotherapy and post-operative spinal radiotherapy was also performed. The CES resolved after the operation and the patient was followed up for 2 years with no recurrence. MRI of intradural cauda equina metastasis may be similar to that of intradural nerve sheath tumor. Surgery and postoperative radiotherapy may be effective for the treatment of CES due to lung carcinoma. Definitive diagnosis is by histopathological examination with immunohistochemistry. If the primary cancer cannot be detected by conventional radiological techniques, PET may be helpful.
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Affiliation(s)
- Kadir Kotil
- Haseki Educational and Research Hospital, Department of Neurosurgery, Istanbul, Turkey.
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Affiliation(s)
- Ba D Nguyen
- Department of Radiology, Mayo Clinic, Scottsdale, AZ 85259, USA.
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Kubota M, Saeki N, Yamaura A, Iuchi T, Ohga M, Osato K. A rare case of metastatic renal cell carcinoma resembling a nerve sheath tumor of the cauda equina. J Clin Neurosci 2004; 11:530-2. [PMID: 15177402 DOI: 10.1016/j.jocn.2003.09.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2003] [Accepted: 09/05/2003] [Indexed: 10/26/2022]
Abstract
We present a rare case of solitary metastasis to the cauda equina from the kidney. The patient was a 68-year-old man with a two-year history of low back pain. His past medical history revealed a renal cell carcinoma diagnosed seven years earlier. His lumbosacral MR imaging showed a well-demarcated, intradural extramedullary mass at the L3 level. He underwent an L2-4 laminectomy. The operative findings of the tumor quite resembled that of a nerve sheath tumor. It did not infiltrate into the subarachnoid space and involved only one spinal nerve. Pathology of the tumor was a metastasis of the renal cell carcinoma. Only 10 cases with such a metastasis to the cauda equina have been reported in the English literature. We added the 11th and reviewed the literature with reference to tumor pathologies, clinical findings and route of metastasis to the cauda equina.
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Affiliation(s)
- Motoo Kubota
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
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Takada T, Doita M, Nishida K, Miura J, Yoshiya S, Kurosaka M. Unusual metastasis to the cauda equina from renal cell carcinoma. Spine (Phila Pa 1976) 2003; 28:E114-7. [PMID: 12642774 DOI: 10.1097/01.brs.0000049910.72881.a0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a case report of a patient with renal cell carcinoma and intradural metastasis to the cauda equina. OBJECTIVE To present a rare case of an intradural metastasis from renal cell carcinoma and to discuss the clinical features of metastatic tumors in the cauda equina and the possible mechanism of the tumor spread to the cauda equina. SUMMARY OF BACKGROUND DATA Intradural spinal metastasis has been rarely reported in the English literature. Only two reports that describe the spread of metastatic renal cell carcinoma to the cauda equina have been published. METHODS A 61-year-old man who underwent a nephrectomy for the treatment of renal cell carcinoma presented with worsening low back pain that radiated to both legs. Magnetic resonance imaging showed an ill-defined tumor mass in the cauda equina at L3. After a recapping T-saw laminoplasty of L3 was performed, the tumor was excised and the nerves involved in the tumor were transected. RESULTS Pathologic examination showed papillary renal cell carcinoma with identical histology to the primary tumor. The patient's low back pain and radiating leg pain were relieved after operating. CONCLUSION The majority of cauda equina tumors are primary tumors, and metastases are very rare. Intradural spinal metastasis pain is a characteristic cramping pain provoked by light percussion on the lumbar spine, becoming severe when sleeping in the flexion or sitting position. Magnetic resonance imaging is a useful tool for detecting intraspinal metastasis when the patient is complaining of a unique pain. A recapping T-saw laminoplasty to preserve posterior elements with tumor removal is feasible for relieving pain and demonstrating the pathology.
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Affiliation(s)
- Toru Takada
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Ghosh S, Weiss M, Streeter O, Sinha U, Commins D, Chen TC. Drop metastasis from sinonasal undifferentiated carcinoma: clinical implications. Spine (Phila Pa 1976) 2001; 26:1486-91. [PMID: 11458156 DOI: 10.1097/00007632-200107010-00022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The first reported case of multiple intradural, extramedullary spinal metastasis from sinonasal undifferentiated carcinoma is presented. OBJECTIVES To elucidate the mechanisms by which metastatic disease invades the spinal axis, and to discuss the possibility of spinal drop metastasis from head and neck tumors that invade the dura. SUMMARY OF BACKGROUND DATA Sinonasal undifferentiated carcinoma is a rare yet aggressive neoplasm of the upper airways and anterior skull base. This neoplasm is known to invade the cranial vault and brain locally. However, it has not previously been reported to seed the cerebrospinal fluid or result in drop metastasis. Such drop metastasis may result in significant neurologic deficit if not diagnosed and treated in a timely manner. METHODS This report is based on a single patient treated by a multidisciplinary team from the departments of neurosurgery, otolaryngology, and radiation oncology at the University of Southern California School of Medicine. RESULTS This patient initially underwent resection and local radiation therapy for sinonasal undifferentiated carcinoma of the anterior skull base. At the time of surgery, the tumor was noted to violate the dura and arachnoid along the subfrontal plane. At 11/2 years after the initial treatment, a bandlike distribution developed at T2 as well as paresthesias and numbness below that level. Imaging of the spine showed an intradural, extramedullary tumor at T2 consistent with a schwannoma or meningioma. The patient underwent a laminectomy and tumor resection, which showed poorly differentiated sinonasal carcinoma. Local radiation therapy was administered, and the patient experienced complete recovery of neurologic function. Bilateral leg pain and weakness developed 14 months later. Magnetic resonance imaging of the spine showed a new intradural, extramedullary lesion at T12, remote from the first lesion. This second metastasis was managed with surgical resection and adjuvant radiation therapy. CONCLUSIONS This is the first reported case of a sinonasal carcinoma leading to intradural extramedullary metastasis. The primary tumor likely seeded the cerebrospinal fluid, thus resulting in drop metastasis. Patients with sinonasal undifferentiated carcinoma that invades the dura should be monitored closely for evidence of metastasis before symptoms develop.
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Affiliation(s)
- S Ghosh
- Department of Neurological Surgery, University of Southern California School of Medicine, Los Angeles, California 90033, USA
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Balagué F, Borenstein DG. How to recognize and treat specific low back pain? BAILLIERE'S CLINICAL RHEUMATOLOGY 1998; 12:37-73. [PMID: 9668956 DOI: 10.1016/s0950-3579(98)80005-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. Specific causes of low back pain are associated with less frequently occurring systemic illnesses including rheumatic, infectious, neoplastic, gynaecological and vascular disorders. The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.
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Affiliation(s)
- F Balagué
- Service de Rhumatologie, Médecine Physique et Rééducation, Hôpital Cantonal, Fribourg, Switzerland
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