Post-irradiation lumbosacral radiculopathy associated with multiple cavernous malformations of the cauda equina: Case report and review of the literature

Radiation-induced cavernous malformations in the spine: patient series

BACKGROUND

Radiation-induced spinal cord cavernous malformations (RISCCMs) are a rare subset of central nervous system lesions and are more clinically aggressive than congenital cavernous malformations (CMs). The authors assessed the characteristics and outcomes of patients with RISCCM at a single institution and systematically reviewed the pertinent literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

OBSERVATIONS

Among the 146 spinal CMs at the authors' institution, 3 RISCCMs were found. Symptom duration ranged from 0.1 to 8.5 months (mean [standard deviation], 3.2 [4.6] months), and latency ranged from 16 to 29 years (22.4 [9.6] years). All 3 RISCCMs were surgically treated with complete resection; 2 patients had stable outcomes, and 1 improved postoperatively. A review of 1240 articles revealed 20 patients with RISCCMs. Six of these patients were treated with resection, 13 were treated conservatively, and in 1 case, the treatment type was not stated. Five of the 6 patients treated surgically reported improvement postoperatively or at follow-up; 1 was stable, and none reported worsened outcomes.

LESSONS

RISCCMs are rare sequelae following radiation that inadvertently affect the spinal cord. Altogether, the frequency of stable and improved outcomes on follow-up suggests that resection could prevent further patient decline caused by symptoms of RISCCM. Therefore, surgical management should be considered primary therapy in patients presenting with RISCCMs.

Cavernoma of the cauda equina

Background:

Cavernomas are benign malformations of the vasculature. In the central nervous system, they are mostly located supratentorially. However, in adults, cavernomas also comprise about 3% of all subdural spinal cord tumors. Notably, cavernomas of the cauda equina are extremely rare, with only 23 cases reported in the literature. Here, we report the 24^th case involving a 77-year-old male.

Case Description:

A 77-year-old male presented with low back pain for 3 years duration. His history included prostate cancer, skin melanoma, and a sick sinus syndrome requiring a pacemaker. An enhanced computed tomography of the lumbar spine showed an inhomogeneously enhanced, intramedullary mass, located at the L3 level. The patient underwent an L3 hemilaminectomy with gross total excision of the lesion. Macroscopically, the tumor was mulberry-shaped and well demarcated. However, it was strongly adherent to a nerve root of the cauda equina which required resection. The histologic examination was consistent with a cavernoma. The patient subsequently fully recovered without a focal neurological deficit.

Conclusions:

Cavernomas of the cauda equina are extramedullary, arise on the inner aspect of the dura, and may be tightly adhered to the nerve roots. To attain gross total excision, the involved nerve may have to be sacrificed; in some cases, this may result in a permanent neurological deficit. Of interest, half of the cauda equina lesions were previously found in patients who had prior radiotherapy; this was not the case in this patient.