842 - Considerations for Advanced Spinal Imaging in Adolescents with Back Pain Lacking Neurological Symptoms: A Case Report

Case Diagnosis:
Extramedullary Intradural Schwannoma



Case Description: An 18-year-old female without significant medical history presented with mid-thoracic pain. The pain began two-months prior to evaluation after a fall downstairs. The pain was characterized as constant, 6/10, non-radiating pain in the mid-back, worsened with movement and improved with rest, ice, and over-the-counter medications. On evaluation, the patient was without neuropathy, bowel/bladder changes, upper motor neuron symptoms, unintentional weight loss, or myotomal/dermatomal abnormalities. Radiographs of the spine were without significant findings. Patient completed physical therapy with complete resolution of her initial complaint. Subsequently, 10 months later, she developed new pain starting in the lumbar spine radiating to the anterior chest wall without lower extremity pain or neurologic findings. MRI of the thoracic/lumbar spine was obtained and revealed an intradural extramedullary mass. Neurosurgery was consulted and resection of the mass was performed shortly after. Patient symptoms resolved with return to prior level of function.


Discussions: This is an atypical presentation of spinal neoplasm causing back pain. The patients age, lack of neurologic symptoms or red flags, as well as relief of symptoms with physical therapy alone may have led to initial misdiagnosis. Improvement of malignancy related pain with physical therapy alone is uncommon and the migratory pain patterns additionally contributed to difficulty in this case. Due to the duration from initial successful intervention to reemergence and development of new symptomatology, standard of care and insurance would indicate repeating conservative treatments and workup. By obtaining advanced imaging, due to similar nature and proximity of pain with variation from initial presentation, definitive treatment was able to be accomplished prior to malignant spread or worsening of symptoms.


Conclusions: Advanced imaging should be considered in adolescent patients with refractory back pain without neurological symptoms or red flags.