Working Diagnosis:
Spinal nerve sheath tumor.

Treatment:
Patient was referred to neurosurgery who recommended surgical management. He underwent T8-T9 laminectomy for gross total resection and final pathology revealed Schwannoma (WHO grade 1).

Outcome:
Two weeks post-surgery, he only needed over the counter medication for mild incisional pain, and he had a normal neurological physical exam. He was started on a gradual return to activity program with a 10-15-pound weight limit and instructions to avoid bending for 6 weeks postoperatively. This was followed by a 25-pound weight limit and allowance to bend at the waist. At his last follow-up visit, his rib pain had completely resolved, and he was able to sleep, cough and go up and down stairs without aggravation of symptoms.

Author's Comments:
Back pain has a wide prevalence range among athletes, with thoracic back pain being less common than lumbar. Also uncommon are spinal tumors (ST) which are categorized by their locations. Intradural extramedullary tumors account for less than half of all ST with the most common being schwannomas and meningiomas. The median time to diagnosis is 12 months and pain is the most common initial symptoms. MRI is the preferred imaging modality and surgical resection is often required to prevent neurologic compromise. Though ST are rare, they are an important differential to consider in adults complaining of thoracic back pain that dose not resolve with conservative management.

Editor's Comments:
Though most cases of back pain have benign etiologies, it can be difficult to tease out more sinister causes during an initial clinical exam. In addition to eliciting a thorough description and history of the pain, inquiring about a focused review of systems during all evaluations of chronic back pain may aid in diagnosis and further decision-making. This patient had a largely normal review of symptoms, except for his complaint that his pain was worse at night. B symptoms can indicate malignancies or infection and include systemic symptoms like night-time pain, fever, unintended weight loss, chills, and night sweats. Cord compression symptoms include bowel and bladder incontinence, imbalance, progressive weakness in extremities, or worsening loss of sensation. While including these questions will not guarantee a clinician will accurately identify all dangerous causes of back pain, the systematic review of systems in combination with thorough neurological exam, will reduce the likelihood that urgent or emergent etiologies will not be missed.

References:
1. Koeller KK, Shih RY. Intradural Extramedullary Spinal Neoplasms: Radiologic-Pathologic Correlation. Radiographics. 2019 Mar-Apr;39(2):468-490. doi: 10.1148/rg.2019180200. PMID: 30844353.
2. Wein S, Smith D, Bickle I, et al. Intradural extramedullary spinal tumors. Reference article, Radiopaedia.org (Accessed on 30 Jul 2024) https://doi.org/10.53347/rID-19239
3.Soderlund KA, Smith AB, Rushing EJ, Smirniotopolous JG. Radiologic-pathologic correlation of pediatric and adolescent spinal neoplasms: Part 2, Intradural extramedullary spinal neoplasms. AJR Am J Roentgenol. 2012 Jan;198(1):44-51. doi: 10.2214/AJR.11.7121. PMID: 22194478.
4. Kumar N, Tan WLB, Wei W, Vellayappan BA. An overview of the tumors affecting the spine-inside to out. Neurooncol Pract. 2020 Nov 18;7(Suppl 1):i10-i17. doi: 10.1093/nop/npaa049. PMID: 33299569; PMCID: PMC7705529.

Return To The Case Studies List.