most commonly they arise from cells lining of the central canal within the spinal cord and present as intramedullary tumor .
a 59-year - old woman complained of pain in neck over the past 6 years .
about 10 months before , she came to us ; she noted pain in her back which was radiating down the lower limbs to the little toes . as a result , she has to stop after walking a little while .
she also started experiencing fear of fall when walking . on examination , her triceps were weak , especially on left .
magnetic resonance imaging ( mri ) scan of spine showed lobulated , conglomerate and discrete idem tumors from d4 to l3 vertebral bodies .
they were hypointense on t1w and hyperintense on t2w [ figure 1a - c ] .
( a - c ) are t2 weighted sagittal magnetic resonance imaging of spine showing multiple intradural extramedullary tumors in dorso - lumbar region .
( d and e ) are t1 weighted postcontrast sagittal and axial images respectively showing areas of the tumor enhancement on the basis of mri image , we suspected lymphoma , and hence we decided to excise the cervical tumor for histology .
on opening the dura , two separate pale brown , mildly vascular and fleshy tumors were seen deep to the arachnoid , one above the other .
they were seen to be adherent to the spinal cord but did not expand it .
they were not continuous but consisted of separate tumors one above the other as in the neck .
we removed two more tumors and as in the neck , found them adherent to the spinal cord without expanding it .
postoperatively , the patient showed some improvement in her lower limbs and she could walk without fear of fall .
the above finding was suggestive of suggestive of low - grade ependymoma [ figure 2a and b ] .
( a 10 and b 40 ) hematoxylin and eosin ( h and e ) stained images showing radially arranged ependymal cells with fibrillary processes .
pseudorosettes are seen with no mitotic activity six weeks after the operation , she was treated by radiotherapy with 28 fractions of 1.8 gy - the total dose being 50.4 gy . at follow - up of 11 months , patient is doing well .
though 20 cases of purely idem ependymomas have been reported in the literature , in most of these cases , single lesion was found .
reported cases of multiple primary idem ependymoma in a first report of idem ependymoma in 1951 , cooper et al .
so in glial tumors presenting as idem lesions : 
 there is a lack of an apparent infiltration into the central nervous system.there is an absence of a primary neoplastic process within the brain or spinal cord.the tumors show encapsulation , are located along the neuraxis and are frequently association with congenital anomalies .
there is an absence of a primary neoplastic process within the brain or spinal cord .
the tumors show encapsulation , are located along the neuraxis and are frequently association with congenital anomalies .
these criteria are ependymomas usually arise from the ependymal cells lining the ventricles and central canal of the spinal cord .
however , idem ependymomas may arise from heterotopic ependymal cell rests were left in the idem space when the neural tube closed . as with typical intradural ependymomas ,
idem ependymomas occur irrespective of age but are most common in the third to fifth decades of life .
the overall prevalence of the majority of intradural ependymomas among males and females is equal , but , in multiple idem ependymomas are common in males [ table 1 ] .
most spinal idem ependymomas affect the thoracic spine in contrast to intramedullary ependymomas , mainly located at the cervical spinal cord and the conus medullaris .
neither the presenting symptoms nor the imaging features of idem ependymomas are different from other common idem tumors like schwannoma or meningioma .
therefore , mostly they are mistaken for schwannoma or meningioma and diagnosis is delayed . though radical excision is recommended for ependymomas in general and near total resection
is advisable for single idem ependymoma , it seems to be unrealistic and risky in cases of multiple idem ependymomas . in all the reported cases , decompression of the lesion causing mass effect was carried out followed by radiation in 2 cases and chemo - radiation in a single case .
though role of radiation in such cases is controversial , biopsy of the symptomatic lesion followed by radiation seems to be the most rational option of this rare entity .
a biopsy of the most symptomatic lesion followed by radiotherapy perhaps represents to be the most preferable option .
 spinal ependymoma commonly presents as an intramedullary tumor . 
 we present a rare case of multicentric intradural extramedullary spinal ependymoma . 
 a 59 years old female presented to us with spastic quadriparesis for 10 months . 
 magnetic resonance imaging of the spinal cord showed discretely located enhancing tumor masses from at c1-c2 , c6-c7 , and d4 to l3 level . 
 subtotal resection of the symptomatic tumor at c6-c7 and d7-d9 was done . 
 the patient underwent radiotherapy with 50.4 gy . at follow - up of 11 months 
 , patient is doing well . 
 the relevant literature is reviewed . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
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