Myxopapillary ependymoma of the conus, case 1

Clinical history
This 19-year-old man complained of severe low back pain for more than one year. Recently, he experienced loss of strength in both legs and right sciatica. A CT scan was normal. The L3-L4, L4-L5, and L5-SI disc levels had been studied and a disk herniation, suspected clinically, was ruled out. MRI was performed as the patient experienced severe pain unexplained by CT.

Neurological examination
As classically reported in similar cases, only a mild objective neurologic deficit was present, characterized by a bilateral Lasègue sign (straight leg raising test).
McCormick Degree of disability grade II, with absence of urinary disorders.

Pre-operative MRI
Images 1 - 4: Sagittal T1WI reveal an intradural lesion, iso-intense to the conus with well defined borders. The inferior extent of the lesion is at the L3 level, which explained the normal CT.
Images 5 - 7: Sagittal Gd T1WI.
Image 8: Axial Gd T1WI. The lesion enhances homogeneously.

The differential diagnosis was neurinoma versus ependymoma.

Surgery
Complete removal of a L1-L3 tumor in March 1989.

Histology
Myxopapillary ependymoma of the conus grade II.

Post-operative clinical course
The patient recovered completely after surgery. Radiotherapy was delivered and post-operative MRIs were performed, first every six months for two years, and eventually only once yearly.

Follow-up MRI (6 years after surgery)
Image 9: Sagittal T1WI and image 10: Gd T1WI. Only post-operative and post-radiotherapy changes are seen: L1-L3 laminectomy with hyperintense vertebral bodies of L2-Sacrum due to fatty marrow replacement.

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