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Pain and Spine Medicine

Recurrent Back Pain and Falls in a Patient with Conus Medullaris Neoplasm - The Importance of Comprehensive Imaging in Unknown Diagnoses: A Case Report

Thursday, October 23, 2025
5:00 PM - 6:30 PM MT
Location: Open Kiosks

    Primary Author(s)

  • Steven Le, MD

    Resident Physician
    Schwab Rehabilitation Hospital & Care Network/University of Chicago PM&R Program
    Chicago, Illinois

    • Co-Author(s)

  • Alex Bryan Behar, MD

    Physiatry and Sports Medicine
    Elmhurst Neuroscience Institute
    Highland Park, Illinois

Disclosure(s):
Steven Le, MD: No financial relationships to disclose
Alex Bryan Behar, MD: No financial relationships to disclose
Case Diagnosis: 70-year-old male with persistent low back pain, progressive neurological weakness, and falls

Case Description or Program Description: Patient presented with persistent bilateral low back pain, radiating down both legs, with the right side more pronounced than the left. Initial MRI demonstrated multilevel lumbar stenosis and degenerative changes with severe stenosis at L2-L3. The patient was treated with an L4-L5 interlaminar LESI, which provided complete pain relief for 2-3 days before symptoms recurred. The patient experienced increased falls. Due to his progressive symptoms and recurrent falls, an MRI of the cervical, thoracic, and lumbar spine was ordered to assess for possible myelopathy.

Setting: Outpatient Sports and Spine Clinic

Assessment/Results: Repeat thoracic and lumbar MRI revealed ill-defined intermediate T2 signal nodularity and 3.2 x 0.9 cm expansion of the conus medullaris, concerning for myxopapillary ependymoma. Patient was referred for urgent neurosurgical evaluation with repeat contrast enhanced imaging.

Discussion (relevance): Conus medullaris abnormalities, including neoplasms such as myxopapillary ependymomas, are rare but cause significant progressive neurological decline. In patients presenting with recurrent falls, worsening radicular pain, and transient symptom relief from epidural steroid injections, repeat imaging is imperative to re-investigate for underlying spinal pathology. Although a lumbar MRI had been performed one month earlier, the tumor was not visualized, highlighting the potential limitations of MRI, such as insufficient slice coverage or resolution in the initial study. In this case, the tumor was better visualized on thoracic MRI, emphasizing the importance of comprehensive imaging when evaluating progressive neurological symptoms.

Conclusions: This case underscores the importance of maintaining a high index of suspicion for underlying spinal pathology in patients with persistent back pain and progressive neurological symptoms. Myxopapillary ependymomas should be considered in cases of unexplained conus medullaris abnormalities, particularly with progressive neurological decline. Limitations in initial imaging studies should be considered, and repeat or alternative imaging modalities may be necessary for accurate diagnosis.