An Unusual Cause of Lumbar Radiculopathy

• DOI: 10.1007/s11999-015-4284-z
• Publication Date: 2015-04-09T15:24:45Z
• Authors: Jesse Even; Gregory Gasbarro; Liron Pantanowitz; James Kang; Kurt Weiss
• Keywords: Palpation; Back Pain; Medical History; Sitting; Neurological examination

History and Physical Examination A 46-year-old man with no significant medical or family history was referred to our tertiary spine surgery clinic for evaluation. He had been having low back pain right lower extremity originating in his posterior thigh radiating foot since lifting some heavy equipment approximately 1 year before presentation us. originally sought treatment a chiropractor, which did not alleviate symptoms. then presented primary care physician, who ordered physical therapy, the patient completed without any relief of leg pain. His physician MRI lumbar sent epidural steroid injections, again provide The also began course gabapentin (600 mg orally, three times daily). On further questioning at clinic, stated that he being treated hamstring strain by ipsilateral radicular symptoms several months. claimed discomfort exacerbated riding on lawnmower sitting car. examination revealed normal strength extremity, decreased sensation along plantar heel lateral foot, Achilles reflex. prone position showed large, palpable mass deep soft tissues positive Tinel's sign, radiated palpation. We reviewed previous MR images subsequently plain radiographs (Fig. 1), gadolinium contrast evaluation (Figs. 2, 3). Based patient's history, examination, imaging studies, what is differential diagnosis this point?Fig. 1: radiograph femur shows tissue compartment (arrows).Fig. 2: An axial T1-weighted fat-saturated image hyperintense thigh, from sciatic nerve.Fig. 3: sagittal short inversion time recovery nerve.Imaging Interpretation Prior outside hospital obvious spinal disorder concordant Plain density aspect thigh. large (6 × 7 cm) encompassing nerve. lesion 2) tau 3) images. Differential Diagnosis Spine Lumbar stenosis Herniated disc Degenerative spondylolisthesis Pelvic Retroperitoneal bleeding Piriformis syndrome Tumor Intraneural Schwannoma perineurioma Neurofibroma Neurolymphomatosis Malignant peripheral nerve sheath tumor (MPNST) Compressive Leiomyosarcoma Rhabdomyosarcoma Lipoma Extraosseous Ewing sarcoma Metastasis how should be treated? Histology ultrasound-guided biopsy performed. Pathologic aspirated material malignant small, round, blue cells necrosis 4) were immunoreactive CD99. Fluorescence situ hybridization EWSR1 t(11;22) translocation 5).Fig. 4: fine-needle aspirate malignant, blue, round (Stain, hematoxylin & eosin; original magnification, ×600).Fig. 5: fluorescence gene 22q12 cells.Diagnosis sarcoma. Discussion Treatment Low radiculopathy are among most common bring patients emergency rooms, clinics, neurosurgical orthopaedic clinics. frequent causes these herniated nucleus pulposus, stenosis, degenerative spondylolisthesis. majority (90%) will resolve surgical intervention need advanced imaging. Most can surgery, using NSAIDs, and/or activity modifications. When persist despite nonsurgical approaches, indicated. However, extremely sensitive has shown display radiographic findings 50% people clinical [9]. If persist, may indicated if etiology spinal, as it commonly is. correlation critical; patient, learning concurrent prompted discovery examination. Thus, we provided an important clue directed extremity. Tissue sampling obtained histologic Results immunoreactivity translocation, confirming extraosseous 5). diagnoses case systematically divided pelvic, appendicular causes. include disc(s), These develop root impingement often follow specific distributions present patient. Furthermore, reveal anatomic pathologic features, making less likely. Extraspinal have described retrospective reviews [10, 11]. arise extrinsic compression lumbosacral plexus traverses true pelvis L3-S4 roots coalesce form exit through greater foramen. neuropathy foramen provocative maneuvers such flexion, adduction, internal rotation. typically normal. As such, based Similarly, retroperitoneal cause signs Patients hypotension serologic abnormalities setting trauma coagulopathy, evident case. Appendicular extraspinal tumors [11]. connective perineurium, myelin-producing Schwann cells, infiltration lymphoma nontumor lymphocytes. consistent therefore, critical guidance therapy. (or neurilemoma) adults affect motor sensory nerves. well encapsulated analysis Antoni B structures pathognomonic Verocay bodies, none benign, painless, slowly progressive associated loss function affected Histologic pseudo-onion bulbs concentric intraneural lamellar proliferations perineural immunohistochemistry epithelial membrane antigen S100 protein, both negative Neurofibromas nonmyelinating found young type I neurofibromatosis later life sporadic. Our characteristic café-au-lait spots axillary freckling. specimen show fibroblast predominance elongated, wavy nuclei therefore inconsistent diagnosis. rare caused direct spread non-Hodgkins paraneoplastic mechanism proximal roots. This entity widespread first manifestation relapse, Finally, presents In hypointense T2-weighted reveals spindle positivity. Soft compressive mechanism. arises smooth muscle lining blood vessels. intramedullary osteolytic lesions metaphysis long bones extend into compression. would heterogeneous areas hyperintensity features actin vimentin children, but alveolar pleomorphic subtypes occur adults. Immunohistochemistry strong positivity MyoD1, myoglobin, myosin, desmin, vimentin. lipomas, benign mature adipocytes, bland, hypocellular stroma adipose tissue. ruled out evaluation, metastases. Examples considered lung cancer melanoma. well-known, bone James “endothelioma bone” 1921 [5]. report here sarcoma, others [1]; however, nerves only few reports [6, 7, 13, 14]. Typically, neoplasm occurs children adolescents, second decade fewer than 20% all cases occurring after age 20 years [8]. reported even elderly late ninth [12]. Typical includes pain, swelling, fever, leukocytosis [3]. Pathologically, belongs cell tumors, neuroblastoma, medulloblastoma, rhabdomyosarcoma, retinoblastoma, lymphoma, Wilm's tumor, primitive neuroectodermal closely related Owing number similar cytologic appearance, imperative make correct because great differences prognosis. Pathologists use myriad techniques, including (CD99, synaptophysin) cytogenetic analyses, evaluate presence classic Type 90% 95% [2, 4, 15-17]. Once confirmed regimen consists neoadjuvant chemotherapy, resection, consolidation chemotherapy. External-beam radiotherapy reserved indications, lie beyond scope manuscript. case, staging CT scans chest, abdomen, negative. preoperative sessions (vincristine, ifosfamide, doxorubicin, etoposide [VIDE]) chemotherapy repeat decrease size 4 cm 6). taken operating room weeks last treatment. approach developed sharp dissection, blunt electrocautery. peroneal tibial identified, ligated, transected distal while dissection nerve, ligated 7). circumferentially dissected free surrounding delivered en bloc field. mobile around suggesting margins 8). Pathological margins, extensive necrosis, marked fibrosis postoperative course, two cycles adjuvant VIDE four vincristine, actinomycin, uneventful regained expected ankle dorsiflexion absence. remains local recurrence metastatic disease followup, 19 months index procedure work laborer. wears ankle-foot orthosis brace other assistive devices.Fig. 6A-B: (A) (B) shown.Fig. 7: Intraoperative isolation amputation performed.Fig. 8: intraoperative resection shown.