Primary spinal intradural extramedullary lymphoma causing cauda equina syndrome
This 11-year-old boy presented with 3 days history of progressively increasing radicular pain over the sacrogluteal region bilaterally; left side more than the right side, along with lower limb weakness and sensory impairment in both lower limbs. He also developed urinary retention and was catheterized elsewhere 1 day prior to his presentation. On examination, his cranial nerves and upper limbs were normal. He had asymmetrical lower limb weakness with the left side worse than the right. His sensory examination also revealed an asymmetrical sensory impairment in the lower limbs with the upper limit being D12 dermatome. Both knee jerk and ankle jerk were absent with plantars not being elicitable. His muscle tone and bulk were normal. He did not have any neurocutaneous markers, palpable lymph nodes or spinal deformity. With this presentation and neurological examination, a diagnosis of spinal cord pathology with clinical localization to cauda equina was made. An emergency magnetic resonance imaging (MRI) of the lumbosacral spine with screening was performed, which showed a well-defined sausage shaped intradural lesion at L2, L3 level, without evidence of any other central nervous system (CNS) lymphomas. The lesion was iso-intense in T1- and T2-weighted images []. He underwent emergency L2, L3 laminectomy and excision of intradural extramedullary lesion. The lesion was removed piecemeal. Intra-operatively the lesion had some attachment to the anterior dura. Total removal was carried out, with coagulation of the anterior dura.\nPost-operatively he had total relief of pain and his motor power improved by one Medical Research Council grade and sensations were slowly improving. Histoplathological examination of the tumor revealed a dense infiltration of round cells admixed with cells with a large eosinophilic cytoplasm and vesicular nucleus with prominent nucleolus, which was consistent with non-Hodgkin's lymphoma []. The diagnosis was confirmed by immunohistochemistry showing CD20 positivity. Detailed investigation was carried out to stage the disease, which included complete hematological examination, including bone marrow aspiration and computerized tomography of the chest and abdomen. All the above investigations were normal.\nOn follow-up after 1 month he had received radiotherapy to the local area of 32 Gy in 20 fractions and was on chemotherapy; cyclophosphamide, hydroxydaunomycin, oncovin-vincristine, and prednisone regimen. Post-operative MRI showed total excision of the lesion []. At 1 year follow-up, he was having near normal power, normal sensations, and normal bladder control.