Author: Dr Ngian Kite Seng & Dr Tan Chong Tien & Dr James Tan
Date: May 2011 Issue
In this issue, a rare cause of upper limb numbness is presented. She was worked up and found to have an intrinsic spinal lesion. We are giving a GP symposium on the 28 May at Mt Alvernia Hospital. The spine team will cover recent advances in treatment of spinal disorders from vertebroplasty to minimally invasive and endoscopic procedures.
Presentation
Mrs K is a 42 year old Indonesian banker who presented with 2 month history of intermittent numbness in her upper limbs. She noticed an increased difficulty with her hand-writing and her arms were tired easily. There was no preceding history of trauma. Pain was not one of the symptoms noted. She was treated for ‘slipped disc’ with physiotherapy by her doctors in Indonesia but her numbness increased over time.
Physical Findings
On examination, she was found to have a normal gait. Her tone and power was normal as well. Exaggerated reflexes in both her upper limbs were detected. Sensation to light touch was diminished over the right C5 and C6 dermatome and over the C5-C8 dermatome on the left. Pin prick and temperature sensation were similarly affected.
Imaging Studies
MRI with contrast of her cervical spine showed an intramedullary lesion at C6 level. It was a mass lesion that expanded the spinal cord. The enhancing nature as well the presence of a cyst at the upper end of the mass pointed to the likely hood of this being a ependymoma.
Treatment
Surgery was performed via laminectomy at C5 and C6. Dura was opened and the spinal cord split open in the midline. A reddish mass that was distinct from the surrounding spinal cord was encountered and the presence of a clear margin between the lesion and the spinal cord allowed complete excision of the tumour. Her post operative recovery was uneventful.
Histology
The tumour was confirmed to be ependydoma, WHO Grade 2. As complete excision was achieved, she did not need to receive any adjuvant therapy. Her one year follow up MRI show no evidence of tumor.
Discussion
Intraspinal tumor as a cause of parathesia is rare. The history of this patient was suspicious as the symptoms were intermittent and non radicular in nature. Tumours of the spinal cord occur in about 2-4% of all central nervous systems tumours. The most common kinds of intramedullary tumors are ependymomas, astrocytomas, and hemangioblastomas.
In adults, ependymomas are the most common tumor type, accounting for 40-60% of all intramedullary spinal tumors, with the mean age of presentation being 35-40 years. Ependymomas are usually indolent and are well encapsulated tumors that are histologically benign. Pain and neurologic deficits arise as a result of a progressive stretching and distortion of nerve fibers. Usually a clear anatomical plane is present at surgery, and a gross visual anatomic resection results in a cure.
Conclusions
Ependymomas is a tumour that can be surgically cured if it is small and detected early enough. The clear plane between tumour and spinal cord allows for accurate dissection with minimal post operative deficits.
