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INTRODUCTION: Endometriosis is a common gynaecologcial disorder and is characterized by the presence and implantation of endometrial epithelium and glandular stroma in an extrauterine location Intraspinal endometriosis can involve the intramedullary, subarachnoid, intradural-extramedullary, and extradural compartments, including the vertebral bodies. Symptoms due to intraspinal endometriosis will vary depending on the location and degree of compression of neural structures and will fluctuate with the menstrual cycle. PRESENTATION OF CASE: A 20-year-old Sri Lankan female with recurrent catamenial backpain, presented to the neurosurgical clinic with acute cauda equina syndrome. She had a history of cyclical lower back pain and lower limb radiculopathy and had undergone spinal decompression and excision of a haemorrhagic cyst in the conus medullaris on three occasions over the past three years. Clinical, radiological and histological discordance meant that the diagnosis of intraspinal endometriosis was missed previously. She underwent repeat spinal decompression on this occasion with histology confirming an endometrial cyst. DISCUSSION: Intramedullary spinal cord haematomas are rarely encountered in neurosurgery. Vascular or neoplastic causes are common with endometriosis being extremely rare. The lack of clinical suspicion, radiological imaging supporting an alternate diagnosis, along with lack of histological confirmation led to the initial diagnostic dilemma and delays in starting long term endometrial suppression therapy. CONCLUSION: Intraspinal endometriosis is a rare but important differential diagnosis in the evaluation of a female in the reproductive age group with cyclical lower back pain and neurological symptoms. One must have a high degree of suspicion regarding it, in order to prevent protracted morbidity.
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When considering tumors of the bone, metastatic disease from a distant primary is more common than primary tumors of the bone itself. The commonest sites to which skeletal metastasis occur are in the axial skeleton, and with regard to the appendicular skeleton, metastasis to the forearm bones is uncommon. Almost a third of patients who present with skeletal metastases do not have any evidence of their primary tumor at presentation. We report a case of a 68-year-old female diagnosed with lung adenocarcinoma after presenting with metastatic deposits involving the right radius as the first clinical manifestation of her disease. She presented initially complaining of painful swelling of her right forearm for a duration of one year. Imaging investigations of her right forearm showed an expansile mixed lytic and sclerotic lesion involving the full length of the right radius. A contrast-enhanced computed tomography scan of her chest to investigate the possible site of primary malignancy showed a peripherally located, well-defined, irregularly shaped mass lesion with enlarged mediastinal lymph nodes. A fluorodeoxyglucose positron emission tomography (FDG-PET) bone scan also noted oligometastatic disease in her right proximal humerus. She was started on palliative docetaxel for six cycles with palliative external beam radiotherapy. Although a variety of tumors metastasize to the bone, metastasis to the appendicular skeleton, and in particular the forearm bones, is a rare phenomenon that is poorly described in the existing literature. Skeletal metastasis may also be the primary presenting feature in a minority of cases. Lung cancer is among the more commonly associated primary sites, and further workup should include appropriate imaging to evaluate for a lung primary as well as an FDG-PET/CT or a bone scan to detect occult metastatic disease.