Kasus: A 44-Year-Old Man With Back Pain and Progressive Weakness

Background

A 44-year-old man is referred for neurosurgical evaluation secondary to a 6-month history of progressive bilateral lower extremity numbness and weakness. Additionally, he reports a history of back pain over the past 4 years that he describes as an occasional sharp shooting pain down his right thigh. The only medication that he has taken is ibuprofen for pain relief. His surgical history only includes an appendectomy at 14 years of age. He denies tobacco, alcohol, or illicit drug use.

Figure 1

On physical examination, his oral temperature is 98.6°F (37.0°C). His pulse has a regular rhythm with a rate of 68 beats/min. His blood pressure is 123/89 mm Hg. He is awake, alert, and oriented to time, person, place, and situation. The cranial nerves II-XII are grossly intact, and the patient's pupils are 3 mm and reactive to 2 mm. His extraocular movements are intact. Face, tongue, uvula, and shoulder shrug are symmetric. The motor examination of the lower extremities reveals 5/5 strength in his bilateral hip flexors and knee extensors. He has 4/5 strength with right dorsal and plantar flexion and 5/5 strength with left dorsal and plantar flexion. Sensory examination reveals intact sensation to vibration, but he has reduced pinprick sensation from the midcalf and below bilaterally. Deep tendon reflexes are 1-2+, with absent bilateral ankle clonus. He has an equivocal left Babinski response with downgoing toes on the right. The patient's gait is normal.

Figure 2

Figure 3

      

MR images with and without contrast of the thoracic and lumbar spine are obtained, which reveal a posterior epidural mass involving the T12-L1 level (Figures 1-3). Signal characteristics of the mass include homogeneous isointense signal intensity on T1 (Figure 1), homogeneous high signal on T2 (Figure 3), and uniform homogeneous postcontrast enhancement (Figure 2). There is associated mass effect on the dorsal aspect of the spinal cord without signal changes within the cord to suggest edema or myelomalacia. The mass does not extend into the adjacent neuroforamina nor does it involve the osseous structures and the adjacent intervertebral disks, which have normal signal and appearance. The paraspinal musculature and soft tissues have a normal appearance. The visualized portions of the thorax and abdomen are unremarkable. Laboratory analysis, including a complete blood count and a basic metabolic panel, is normal.

What is the most likely diagnosis?

Hint: Note the location and the postcontrast characteristics of the mass.

Epidural cavernous hemangioma

Epidural abscess

Ependymoma

Epidural hematoma