A Huge Far Lateral Lumbar Disc Herniation Mimicking Nerve Sheath Tumor: A Case Report

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1 C a s e R e p o r t J. of Advanced Spine Surgery Volume 4, Number 1, pp 28~32 Journal of Advanced Spine Surgery JASS A Huge Far Lateral Lumbar Disc Herniation Mimicking Nerve Sheath Tumor: A Case Report Yung Park, M.D., Joon Woo Han, M.D., and Joong Won Ha, M.D. Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Yonsei University College of Medicine Far lateral lumbar disc herniation (FLLDH) is a rare type of intervertebral disc herniations based on its anatomical location. A herniated lesion compressing the exiting nerve root superiorly makes clinical symptoms of lumbar radiculopathy. We report a 77-year-old female patient presenting lower back pain, left buttock pain and numbness, radiating pain, tingling sensation on the left lower extremity. Radiological images revealed a 16.2x13.8x7.2 mm sized mass like lesion outside the left foraminal canal of the L5-S1 disc space, mimicking nerve sheath tumor at a extradural location. Histopathological examination of the specimen was confirmed as a sequestrated disc fragments. We conclude that preoperative careful evaluation should be exercised for the differential diagnosis of the extraforaminal soft mass. Key Words: Far lateral, Extra-foraminal, Huge sized, Lumbar disc herniation, Differential diagnosis, Nerve sheath tumor Introduction Radiculopathy is a term for dysfunction of nerve roots due to many reasons and it causes pain, numbness motor weakness of the involved nerve. Clinically, one of the main reasons for radiculopathy caused by nerve compression outside the spinal foramen at the lumbar level, would be herniated lumbar disc extruding laterally to the extraforaminal area. Nevertheless, if the radiculopathy is thought to be caused by a hugh mass like lesion compressing a single nerve root outside the foramen, confirmed by multiimaging studies, the probability of mass effect by tumor cannot be excluded. Such tumor includes neurofibromas, schwannomas, melanotic cysts. 1,2,3) In this report, we present one case of a 77-year-old female patient with huge FLLDH mimicking tumor like mass who underwent surgical procedure. Case Report A 77-year old female was suffered 2 weeks from lower back pain, left buttock pain and numbness, radiating pain, tingling sensation on the left lower extremity. Each VAS score for back pain and lower extremity pain was 10 and ODI score was 50/50. Severe pain made her wheelchair bound, but there were no motor weakness and sensory disturbance. Straight leg raise test and femoral nerve stretch test revealed no abnormal finding. Plain radiographs of her lumbar spine reveals a healed vertebral compression fracture at the level of the first lumbar vertebrae and degenerative spondylosis (Fig. 1). CT scan shows mm sized mass like lesion outside the left foraminal canal of the L5-S1 disc space (Fig. 2). Axial T1-weighted image and Axial T2-weighted image both shows disc contour mass located extra-foraminal at the L5 Corresponding author: Yung Park, M.D. Department of Orthopedic Surgery, Yonsei University College of Medicine, National Health Insurance Service Ilsan Hospital. 1232, Baekseok street, Ilsan district, Goyang city, Gyeonggi province, , Republic of Korea. TEL: , FAX: Copyright 2014 Korean Society for the Advancement of Spine Surgery

2 root exiting space, compressing the left L5 nerve root. Axial Gadolinium-enhanced image showed rim enhancing features of the mass (Fig. 3). Left paraspinal approach was undergone directly to the Fig. 1. Plain radiographs of her lumbar spine reveals a healed vertebral compression fracture at the level of the first lumbar vertebrae and degenerative spondylosis. Fig. 2. Coronal (A) and Axial (B) images of CT scan. A 16.2x13.8x7.2 mm sized mass like lesion is located lateral from the left foramen to the sacral ala, migrating superiorly. 29

3 Fig. 3. Axial MR images of T1-weighted (A), T2-weighted (B) and Gadolinium-enhanced (C) view. Both T1- and T2- weighted images show disc contour mass located extra-foraminal at the L5 root exiting space. Peripheral enhancement around the non-enhancing mass is seen on a Gadolinium-enhanced view. left extra-foraminal area of L5/S1 disc space in the prone position.left upper margin of the sacral bony ala was drilled using high speed burr. The intertransverse fascia and ligamentum flavum were dissected to expose the soft mass compressing the L5 nerve root and then the mass was removed completely (Fig. 4, 5). The specimen consisted of 2 fragments of irregular white gelatinous to cartilaginous materials, measuring cm in the larger one. Paraffin block pathology was diagnosed as degenerated fibrocartilage (Fig. 6). Patient was discharged 13 days after surgery. In a 6 weeks follow up, VAS score was 3 for back pain and 0 for lower extremity pain and ODI was decreased to 25/50 compared to 50/50 preoperatively. Discussion Far lateral lumbar disc herniation (FLDDH) represents up to 12% of all cases of lumbar nerve root compression. 4,5,6,7) There are many views in defining definition of the terminology but currently the term FLLDH refers to a disc herniation lateral to the neural foramen. Herniated lesions compress the superiorly exiting nerve root and ganglion, resulting clinical complaints. Most frequently far lateral disc herniations are at either the L3-L4 or L4-L5 levels followed by L5-S1. 8,9,10) In addition, this extra-foraminal disc prolapse is often sequestrated, and many migrate superiorly and laterally. 6,11,12) Age of patients with FLLDH are typically in their mid-fifties, ranging from years of age. 8,10,13) Since radicular pain could be caused by numerous disorders, such as intervertebral disc herniation, spinal stenosis, tumor, vascular disease or nerve tumors, differential diagnosis should be narrowed based on history taking, physical examination, and imaging tests. Clinical features and Physical examinations may be helpful for differentiating spinal origin pain from other conditions, but there are no particular characteristics of disc herniations and tumoral lesions. Computed Tomography(CT) can aid in diagnosing 30

4 Fig. 4. Intra-operative views of the surgical field. (A) View through paraspinal approach. (B) After opening of the intertransverse fascia. Hugh disc like mass compressing the L5 nerve root is seen. (C) Removal of the mass. (D) Extra-foraminal space after removing the mass. Fig. 5. Gross appearance of the removed mass. FLLDH by defining and demonstrating the extent of bony diseases. A Magnetic Resonance Imaging (MRI) is more informative than CT scan, owing to its ability to identify other intraspinal pathologies, including tumors. And further to T1- and T2-weighted images, enhanced MR studies with Gadolinium enhancement may differentiate tumor from a sequestrated disc fragment. 14) MR imaging of sequestered disc lesions frequently shows rim enhancement in a Gadolinium-enhanced images produced by covering vascularized granulation tissues. Despite the role of MR imaging, though, the differences between herniations and tumors are inconsistent and are frequently misdiagnosed. 15,16) We report a surgically treated case with severe radiculopathy caused by a huge sized soft mass located in the extraforaminal area. Consequently, that was a herniated lumbar disc confirmed by post-surgical pathologic examination, even its radiologic appearance was considered to be a soft tissue tumor such as nerve sheath tumor. 31

5 Conflict of Interest No potential conflict of interest relevant to this article was reported. REFERENCES 1. Weil AG, Obaid S, Shehadeh M, Shedid D. Minimally invasive removal of a giant extradural lumbar foraminal schwannoma. Surg Neurol Int.2011;2: Chakravarthy H. Melanotic cyst of L5 spinal root: A case report and review of literature. Asian J Neurosurg. 2012;7(4): Murovic JA, Charles Cho S, Park J. Surgical strategies for managing foraminal nerve sheath tumors: the emerging role of CyberKnife ablation. Eur Spine J. 2010;19(2): Abdullah AF, Wolber PG, Warfield JR, Gunadi IK. Surgical management of extreme lateral lumbar disc herniations: review of 138 cases. Neurosurgery. 1988;22: O Hara LJ, Marshall RW. Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br. 1997;79: Frankhauser H, de Tribolet N. Extreme lateral lumbar disc herniation. Br J Neurosurg. 1987;1: Postacchini F, Montanaro A. Extreme lateral herniations of lumbar disks. Clin Orthop Relat Res. 1979;138: Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg. 1995;83: Epstein NE. Review article: Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord. 1995;8(5): Epstein NE, Epstein JA, Carras R, Hyman R. Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-ct in diagnosis and management. Spine. 1990;15(6): Abdullah AF, Ditto EW III, Byrd EB, Williams R. Extreme-lateral lumbar disc herniations. Clinical syndrome and special problems of diagnosis. J Neurosurg. 1974;41: Hood RS. Far lateral lumbar disc herniations. Neurosurg Clin N Am. 1993;4: An HS et al. Herniated lumbar disc in patients over the age of fifty. J Spinal Disord. 1990;3(2): Winter DD, Munk PL, Helms CA. CT and MR of lateral disc herniation: typical appearance and pitfalls of interpretation. Can Assoc Radiol J. 1989;40(5): Ozer E, Yurtsever C, Yucesoy K, Guner M. Lumbar intra-radicular disc herniation: report of a rare and preoperatively unpredictable case and review of the literature. Spine J. 2007;7: Yamashita K, Hiroshima K, Kurata A. Gadolinium- DTPA-enhanced magnetic resonance imaging of a sequestered lumbar intervertebral disc and its correlation with pathologic findings. Spine. 1994;19: 연부종양과감별진단이어려웠던극외측거대요추간판탈출증 : 증례보고 박융, 한준우, 하중원연세대학교의과대학, 국민건강보험일산병원, 정형외과 요추간판탈출증중신경공극외측으로의추간판수핵탈출은그발생빈도가드물고, 특히그크기가클경우연부종양과감별진단이어려울경우가있다. 저자들은심한하지방사통을호소한 77세여자환자에서발생한방사선학적으로연부종양과감별진단이어려웠던거대추간판수핵탈출증을치료한경험을문헌고찰과함께보고하고자한다. 색인단어 : 극외측, 거대탈출, 요추간판, 감별진단, 연부종양. 32

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