Extra genital endometriosis is a frequent occurrence but spinal endometriosis is a rarity and very few cases have been reported in literature with lumbar intradural location being most reported. We report a case of lumbar extradural endometriosis which was reported once in 1992 by Carta et al. Treatment involves combination of surgical and medical measures. Importance of good history taking and clinical suspicion is emphasized.
A 28 years old lady of African descent presented with a 2 years’ history of radiating pain to bilateral lower limbs, mainly in the anterior aspect up to knees (L>R) and together with progressive weakness of the lower limbs. There was pain and swelling at the previous operative site, which worsened with every menstrual period.
In 2016, patient underwent biopsy of the spine lesion, in her home country, which was reported as showing chronic inflammatory tissue? Tubercular.
Post –op she developed left leg proximal weakness, which persisted.
On examination at this presentation and had a tender fluctuant swelling below the previous operative site. She had weakness of both lower limbs, with intact bladder/ bowel function.
MRI of Lumbar spine (2018) shows:
L1-L3 extra dural lesion with patchy contrast enhancement extending extra-foraminally at multiple levels, mainly on the left and involving the left paravertebral tissue and erector spinae muscles up to the subcutaneous tissues. The left L1/L2 foramen was enlarged.
Other investigations included
NCV/EMG lower limbs which showed a left L2,3,4 chronic radiculopathy.
PET –CT : which did not pick up any other avid lesion.
USG abdomen – showed a right shrunken kidney with a bulky uterus and adenomyosis.
She was planned for tumor decompression surgery to establish the diagnosis and improve her neurological deficit. The risks of surgery were discussed with her and then she underwent excision of extra-spinal component of right sided L1-L3 tumor.
Her Intra-op frozen section- s/o endometrial deposit, hence extensive debulking was withheld till definitive diagnosis.
Gynecology consultation was taken and she was given Inj. Zoladex 3.6 mg subcutaneously and advised to continue this injection monthly for 6 months, then review with fresh MRI.
Tissue from extradural lesion in lumbar spine for frozen section showed Extra genital Endometriosis
Tissue from extradural lesion in lumbar spine for paraffin section showed Extra genital Endometriosis.
Immunohistochemistry was positive for estrogen/ progesterone and CD-10 receptors
TREATMENT OPTIONS FOR SPINAL ENDOMETRIOSIS
Medical management: When only pain without neurological deficit
Surgery: In cases with pain with neurological deficit, surgery to debulk / excise the tumor is followed by medical treatment.