Case report
A 24-year-old male came to seek medical attention for three months
history of low back pain associated with the burning sensation of
bilateral lower limbs. For the last 12 days, he was unable to walk due
to gradually progressive weakness in bilateral lower limbs. These
symptoms were not accompanied by fever, headache, and night sweats. He
could not recall any history of trauma in the past. His past medical and
surgical history was not significant.
On examination, there was a localized tenderness over the thoracolumbar
region. Lower limb motor power varied across muscle groups: hip flexors
(2/5 bilaterally), knee extensors (2/5 bilaterally), ankle dorsiflexors
(2/5 bilaterally), long toe extensors (3/5 bilaterally), and ankle
plantar flexors (3/5 bilaterally). The sensation of lower limbs was
altered bilaterally, but bowel and bladder habits were normal. Deep
tendon reflexes in the knee and the ankle joints were absent. Plantar
reflexes were downgoing bilaterally.
With the clinical diagnosis of a space-occupying lesion in the
thoracolumbar spine region, an X-ray of dorsolumbar spine was done.
Apart from the loss of lumbar lordosis, the rest of the X-ray findings
were normal. Magnetic resonance imaging (MRI) of the thoracolumbar spine
with screening of the whole spine revealed extradural lesion extending
from T10 to L2 vertebral level. T1W image showed homogenous lesion which
was iso to hypo-intense and the T2W image showed heterogeneous lesion
which was iso to hyperintense, compressing over the spinal cord dorsally
(Figure 1, 2). Sagittal short tau inversion recovery (STIR) image also
revealed an extra-medullary lesion with high signal intensity to the
vertebral marrow (Figure 3). Chest X-ray, complete blood count (CBC),
liver and renal function tests, erythrocyte sedimentation rate (ESR),
c-reactive protein (CRP), peripheral blood smear, lactate dehydrogenase
(LDH), uric acid and urinalysis were normal. The diagnosis of the
extradural tumor over the T10-L2 vertebrae was made.
Decompression (laminectomy) and excision biopsy of the mass was planned.
The thoracolumbar spine (T9 to L3) was approached midline posteriorly.
After laminectomy, a dorsally located greyish red extradural tumor
extending from T10 to L2 was removed in strips. One of the long strips
of the excised mass (approximately 15 x 1 cm) was sent for
histopathological examination (Figure 4). Histopathology identified it
as DLBCL (Figure 5). Immunohistochemistry analysis showed
CD3-, CD20+,
CD30+, CD10+,
ALK-1-, BCL-6+,
MUM-1- and Ki-67+. No other lesion
was detected on staging evaluation which included contrast-enhanced
computed tomography (CECT) of chest, abdomen, and pelvis, and bone
marrow aspiration and biopsy.
His postoperative period was uneventful with successful recovery in his
symptoms including neurology. He was referred to a cancer center after
16 days of hospital stay where he obtained six cycles of chemotherapy
with rituximab, cyclophosphamide, doxorubicin, vincristine, and
prednisolone (R-CHOP) regimen. After the treatment, the tumor regressed
and he fully regained his muscle power. At the latest, one-year
follow-up, he is asymptomatic and is performing his routine daily
activity.