Extramedullary intradural lesion at level of T9 missed on initial evaluation: A Case Report

Case Diagnosis: Extramedullary intradural lesion at level of T9 missed on initial evaluation

Case Description or Program Description: A 69-year-old female with a history of hypertension, asthma, and coronary artery disease was admitted for shortness of breath and bilateral lower extremity swelling with saddle anesthesia. She denied urinary or fecal incontinence. She had experienced multiple falls in the last six months and transitioned from a cane to a wheelchair for mobility over the past three months.

Setting: Inpatient Acute Hospital

Assessment/Results: MRI of the lumbar spine showed severe canal stenosis at L2-3. Neurosurgery evaluation suggested that the exam was consistent with neurogenic claudication due to lumbar stenosis, and outpatient follow-up was recommended. PM&R was consulted regarding the level of care assessment. During the PM&R evaluation, an ISNCSCI exam was performed, and the patient was found to have significant pinprick and light touch impairment below T9 and mild muscle weakness in both lower extremities with intact lower extremity reflexes. MRI of the cervical and thoracal spine was recommended, given that stenosis at L2-3 was incompatible with examination findings.

MRI of the thoracic spine showed an extramedullary intradural lesion at the level of T9. The patient was started on dexamethasone and radiotherapy. Three months later, she underwent T8-10 laminectomies and tumor resection, with pathology consistent with meningioma.

Discussion (relevance): This case emphasizes the vital role of a thorough neurological assessment in identifying underlying conditions, even when a potential cause is identified on initial imaging workup. The ISNCSCI exam, was critical in revealing the incongruity of the neurological level of injury with the suspected vertebral level of injury; ultimately guiding further investigation and modification of the treatment plan.

Conclusions: A thorough physical examination should always be part of a PM&R evaluation, even for routine discharge planning consults, as it could identify a major medical problem and change the patient’s management.