Attending physician Nationwide Children's Hospital Columbus, Ohio, United States
Case Diagnosis: Radiculopathy from spinal drop metastasis
Case Description: The propositus is a 21-year-old female with past medical history of high-grade glioma originating in the midbrain who presented to a multispecialty neuro-oncology clinic due to several episodes of paroxysmal, severe left leg pain over a ten day period. These episodes lasted 3-4 hours and resolved completely in between. She described her pain as a burning sensation around her left knee which progressed to a sharp, shooting pain from her back down her left leg. Despite attempts at conservative management at home, paroxysmal pain episodes were severe enough to require emergency department visits for intravenous opioids. She denied any weakness, bowel/bladder changes, or new neurologic deficits. MRI spine was completed showing a new compressing lesion at the left L5 neural foramen concerning for drop metastasis. Gabapentin, hydromorphone, and dexamethasone were started, though pain paroxysms persisted. Plans were made to initiate craniospinal radiation therapy.
Discussions: Spinal drop metastasis is an intradural extramedullary neoplasm and rare complication of gliomas. Only 1-2% of patients in all populations with gliomas will experience drop metastasis. The mode of spread is unclear, but the primary thought is tumor extravasation directly through CSF. Surgical debulking or biopsy is a risk factor, though not necessary for occurrence. These lesions can be missed on plain radiographs and CT scans, so MRI is the imaging of choice. Identifying drop metastasis is important, as this is associated with poorer prognosis. Management depends on size, number of lesions, and location. Treatment options include neurosurgery, radiation, and steroids.
Conclusions: While spinal drop metastasis is a rare complication of gliomas, it is important to consider in this population who have sudden onset radicular symptoms. Radiculopathy is a less common cause of pain in patients in their early 20s and illustrates the need for a comprehensive history, physical exam, and diagnostic workup.
