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Year : 2003  |  Volume : 13  |  Issue : 1  |  Page : 103-104
Intradural extramedullary spinal tuberculoma - an uncommon entity


Department of Radiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

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Keywords: Intradural Extramedullary Tuberculoma, MRI

How to cite this article:
Makkar G, Srivastava A, Aggarwal A K. Intradural extramedullary spinal tuberculoma - an uncommon entity. Indian J Radiol Imaging 2003;13:103-4

How to cite this URL:
Makkar G, Srivastava A, Aggarwal A K. Intradural extramedullary spinal tuberculoma - an uncommon entity. Indian J Radiol Imaging [serial online] 2003 [cited 2020 Jun 6];13:103-4. Available from: http://www.ijri.org/text.asp?2003/13/1/103/28640

   Introduction Top


Tuberculosis is a major health problem in developing countries. Moreover severe form of tuberculosis is still rampant. There are various manifestations of central nervous system (CNS) tuberculosis. Of these intradural extramedullary tuberculoma of the spine is an uncommon entity. It comprises 2 to 5% of CNS tuberculomas. There are only 18 cases reported so far in literature [1]


   Case Report Top


A 25 year old man presented with acute onset of weakness in both lower limbs. The patient had an episode of tubercular meningitis 6 months back for which he was receiving antitubercular drugs. The paraplegia was rapidly progressive with both sensory and motor deficit along with bowel bladder involvement. The patient also had a history of flexor spasms. Neurological Examination revealed normal muscle bulk and tone, however power was grade 0/5. Deep tendon reflexes were brisk and Babinski sign was present. Sensory deficit was present below D7 level. There was no clinical evidence of meningitis.

Blood investigations revealed a raised ESR and Leucocytosis with lymphocyte preponderance. CSF examination showed proteins >3 gm% and there were 30 cells on microscopy, all were lymphocytes.

Radiographs of the dorsolumbar spine did not reveal any abnormality. However an MRI showed an intradural extramedullary lesion at the level of D7 vertebra. It was seen to encase the cord and had caused obliteration of the surrounding thecal sac. Epidural fat appeared to be compressed by the lesion. The lesion was iso to hypointense to the cord on T1 weighted images [Figure - 1] and was hypointense on T2 weighted images [Figure - 2] It showed a central hyperintensity on T2W1 suggestive of necrosis. There was homogenous enhancement after intravenous Gadolinium. [Figure - 3]. There was also associated syringomyelia both proximal and distal to the lesion. [Figure - 2] Vertebrae and intervertebral discs were normal. No pre or paravertebral abscess was seen.


   Discussion Top


Mycobacterium tuberculosis can involve the neural and perineural tissues directly and lesions may occur any where within the CNS. Spinal tuberculomas are rare, both as a cause of spinal compression and among tuberculomas generally. Like other intraspinal tumors, tuberculomas may be intradural extramedullary (IDEM), intramedullary or extradural. Intradural extramedullary tuberculous granuloma is the most uncommon form of intraspinal tuberculoma [1][3]

Generally patients with IDEM tuberculoma have a gradual onset of the disease over weeks to years with progressive involvement of motor and sensory pathways. Slow deterioration of neurological symptoms is caused by an expansion of the lesion causing pressure on the cord. Some times it is precipitated by heavy lifting or minor motor accidents. [3],[4]

While the extradural lesions are usually the result of vertebral tuberculosis, most intradural lesions are hematogenous. Dibble and Cascino (1956) suggest that a tubercle forms in the cord, ruptures into the subarachnoid space and causes chemical meningitis. [2] The patient may respond to treatment, but during recovery a tuberculoma forms at the site of the original lesion and later produces cord compression.. Similarly our patient also had a history of meningitis treated with anti tubercular drugs treatment and after 6 months developed compressive myelopathy. Others have shown that a spinal cord tubercle can impinge on the membranes locally and become sealed off from the rest of the nervous system for some time at least. This can explain its presentation in a patient without a history of tubercular meningitis. The strain of lifting heavy objects or a trivial road traffic accident appeared to precipitate an acute illness-possibly by rupturing a wall of the inflammatory tissue surrounding the lesion. [3]

Parsons and Pallis (1965) divided IDEM Tuberculomas into 2 groups. [4] The first group comprises hard round lesions, which are 2 to 3cm in diameter. They have a relatively thin capsule often containing granular calcified material and are usually attached to the duramater but are relatively easily separated from the underlying spinal cord. In the second group, there is diffuse avascular grayish tuberculous granulation tissue encasing the cord. Our patient belongs to the second group.

Previous reports state that medical treatment alone would not improve the status of IDEM lesions and surgical resection of the IDEM tuberculoma followed by antituberculous medication results in good outcome [3][4][5][6]. In our patient too surgery revealed encasement of the cord by a caseating tuberculoma, which was resected. The patient showed considerable improvement after surgery.

 
   References Top

1.Mathuria SN, Khosla VK, Banerjee AK. Intradural extramedullary tuberculous spinal granulomas Clin Neuro Neurosurg 1988; 90: 155-8  Back to cited text no. 1    
2.Dibble JB, Cascino J Tuberculoma of spinal cord JAMA 1956; 162: 461  Back to cited text no. 2    
3.Compton JS, Dorsch NW. Intradural extramedullary tuberculomas of the cervical spine : case report. J Neurosurg 1984; 60:200-3  Back to cited text no. 3  [PUBMED]  
4.Parsons M, Pallis CA Intradural spinal tuberculomas. Neurology 1965 Nov; 15 (11) : 1018-22  Back to cited text no. 4    
5.Kim MS, Kim KJ, Chung CK, Kim HJ. Intradural extramedullary tuberculoma of the spinal cord: a case report : J Korean Med Sci 2000 Jun; 15(3) : 368-70.  Back to cited text no. 5    
6.Turgut M. Intradural tuberculous granuloma . Br. J Neurosurg. 1997; 11:264  Back to cited text no. 6    

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Correspondence Address:
G Makkar
Department of Radiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

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    Introduction
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