A 23-year-old female presented with spastic paraplegia and bowel and bladder involvement of 7 days duration. This was preceded by pain in the dorsal spine, radiating to both lower limbs for 2 months, and progressive weakness and spasticity in the lower limbs for 2 weeks. On examination, she had spastic quadriplegia and loss of all sensory modalities below the D5 dermatome. An urgent MRI of the thoracic spine showed an extradural en plaque spinal lesion located posterolateral to the spinal cord, pushing the dura anteriorly [Figure 2]. The lesion was hypointense on T1-weighted MR, isointense on T2-weighted MR, and intensely enhancing on contrast administration. It arose primarily from the left posterolateral corner of the spinal canal, and extended predominantly dorsally but also ventrally in relation to the cord [Figure 2a-c]. The lesion was traversing the D4-D5 intervertebral foramen up to its outer limit. In view of the extradural location in the spine, the differentials were metastases, lymphoma, or a granulomatous infection like tuberculosis.
The patient underwent emergency D3-D5 laminectomy and decompression of the lesion. Intraoperative findings revealed a vascular and fleshy lesion present over the dura. Unfortunately, frozen section was not done at the first surgery, as this case was taken up as an emergency during the night. Histopathology was unequivocal for meningioma [Figure 3b].
Although the patient improved after decompression, the benign nature of the pathology prompted us to re-explore with a wider left posterolateral approach and perform a total excision of the tumor. At surgery, the tumor could be peeled off the dura, enabling a total excision [Figure 3a]. The patient improved in the postoperative period and has regained grade 5/5 power in both lower limbs, sensations, and bowel and bladder function at 3 months follow-up. Follow-up MRI showed no evidence of residual or recurrent lesion [Figure 2d and h].