A rare case of spinal tumor syndrome with pericardial effusion

Spinal tumor syndrome is a condition caused due to extradural granuloma or abscess causing cord compression and neurological deficits. Spinal tumor syndrome with a concurrent pericardial effusion is a very rare presentation and presents a challenge regarding surgical management due to the high perioperative risks. A rare case of spinal tumor syndrome with pericardial effusion was treated with pericardiocentesis followed by surgical decompression of the spinal cord.

The case report has been published in Journal of Karnataka Orthopaedic Association.

A 73-year-old lady presented with chief complaints of sudden onset weakness of both lower limbs since five days and inability to walk. She had a history of fever one month back for which she was hospitalised and intravenous antibiotics were given. Fever subsided in three days and patient developed severe back pain two weeks later.

She was hospitalised and developed sudden weakness of both lower limbs with inability to walk. There was no bowel or bladder dysfunction. She was referred to the author’s institute five days later. Examination revealed a moderately built and nourished lady with no cachexic features. She had diffuse thoracolumbar tenderness. Both lower limbs had equal muscle bulk and were hypotonic. Hip flexors had a power of 2/5 bilaterally and remaining distal myotomes were 3/5. Knee and ankle jerks were sluggish and there was no plantar response seen. Hypoesthesia was present over L5, S1 dermatomes bilaterally. She came under ASIA-C category (American Spinal Injury Association) with a motor level of T12 and sensory level of L4.

As part of routine preoperative workup a general physical examination was done. Cardiac auscultation revealed muffled heart sounds. Rest of the systemic examination was found normal.

The laboratory investigations showed Hemoglobin-10.6 gm%, ESR elevated to 52 mm/hr, CRP to 19.12 and total leucocyte count of 12,000/mm3 . Urine culture showed a significant growth of Enterococcus faecium. Plain X-rays of the thoracolumbar spine showed rarefaction of the vertebrae with degenerative changes. Chest Xray revealed an enlarged cardiac silhouette.

MRI of thoracolumbar spine showed a loculated hyperintense collection in left posterior paraspinal muscles measuring 11.7x2.9 cm extending from T12 to L4 with epidural granuloma. Extension of collection into posterior epidural space through left neural foramen was seen at T12-L1 and L1-L2 levels. Epidural collection was found to be partially encasing and displacing the cord at T12 level.

Echocardiogram done showed moderate pericardial effusion with impending cardiac tamponade. A diagnosis of Spinal Tumor Syndrome with paraspinal abscess with pericardial effusion, was made.

As proceeding with surgery was risky in view of anaesthestic problems due to the pericardial effusion, immediate pericardiocentesis was done and pigtail catheter was left in situ. The pericardial fluid was sent for analysis and found negative for both tuberculosis and bacterial growth. Post-centesis chest X-ray showed a significant reduction in size of cardiac sillhoutte.

She then underwent Laminectomy of T12, L1 with laminotomy of T11. Granulation tissue surrounding dura and pus from the paraspinal abscess were sent for culures as well as histopathological examination. Nucleic acid amplification test by Polymerase chain reaction showed presence of Mycobacterium tuberculosis in the pus and granulation tissue. Acid fast bacilli (AFB) smear of pus was positive for acid fast bacilli with 1+ concentration. Histopatholog y showed caseating granulomatous inflammation favouring tuberculosis. AFB culture grew Mycobacterium tuberculosis. Patient was started on antitubercular medication as per current protocol. At 6 weeks follow up patient was able to walk with aid, and was able to walk independently at 6 months.

The authors concluded that – “A high index of suspicion for atypical spinal tuberculosis can help in early detection and prompt intervention. Cases of spinal tumor syndrome with concurrent systemic afflictions would benefit from a multidisciplinary approach so that patients can safely undergo early spinal intervention, improving their chances of neurological recovery.”

Further reading:

Spinal Tumor Syndrome with Pericardial Effusion

Srivatsa Nagaraja Rao , Krishnakumar R

Journal of Karnataka Orthopaedic Association

DOI: https://doi.org/10.13107/jkoa.2022.v10i02.052