Primary spinal cord epidural non-Hodgkin's Lymphoma as cause of paraplegia: report of 2 cases

Abstract

Two cases of paraplegia due to primary spinal cord epidural non-Hodgkin's lymphoma (NHL) are presented. This is a rare cause of paraplegia. The clinical presentation, investigations and management of this rare condition are outlined. A review of the literature is presented. Primary spinal epidural NHL should be considered in patients who give a history of back pain; followed by rapid development of features of spinal cord compression; have normal plain x-rays but whose CAT / myelogram reveal an extradural mass. Urgent surgical decompression followed by chemotherapy and radiotherapy improves the outcome of such patients. Primary epidural Non Hodgkin's Lymphoma (NHL) with no evidence of parenchymal central nervous system (CNS) or systemic involvement is rare. Although it may present as a localised disease it is in fact a systemic disease. This disease entity must be differentiated from the more common clinical situation of primary CNS parenchymal lymphoma with meningeal involvement or systemic lymphoma, such as adult cell T lymphoma, complicated by lymphomatous meningitis. A 20-year experience with NHL at the Memorial Sloan Kettering Cancer Centre showed that primary epidural NHL accounted for 2 out of 256 (1.9%) of NHL cases1. A 10-year experience (1979-1989) at the Mayo Clinic report primary spinal epidural NHL accounting for 6.6% of all cases of intraspinal NHL2. Levitt et al report that among 592 cases of NHL seen between 1967 and 1977, 52 patients (11%) had CNS lymphomatous involvement. However they did not specify how many were primary spinal epidural NHL3. With the current AIDS/HIV pan epidemic it is expected that the incidence of primary spinal NHL will increase. Distinguishing primary spinal NHL from an infectious spinal mass may be difficult as both would present with similar features of meningitis, fever, night sweats and weight loss.

Figure 1a

Figure 1b

Myelogram for LT showing a right posterolateral compressive mass at T9 – T10 level. No evidence of bone destruction noted.

Figure 1c

CT scan at level of mass. A right sided lesion is seen displacing the spinal cord to the left. There is an extension through the intervertebral foramen

Figure 2a

Lateral view myelogram of MC showing a posterior compressive mass extending over several vertebral segments.

Figure 2b

Figure 2c

Figure 2d

CT scans at various levels. Fig 2b shows a posterior mass displacing the cord anteriorly. Fig 2c and 2d are scans at levels above and below the mass respectively showing that the spinal cord is centrally located in the spinal canal