The patient came to the clinic 31-July-2011 complaining of numbness both legs for one month with progressing course, more the right with unsteady gait and LBP. Right shoulder and neck pain. The patient is a known diabetic under treatment for 10 years, hypertensive for 10 years in Atakand, and his son noticed loss of weight 12Kg the last 2 months.

MRI cervical done 15-June-2011 showing small PCD C2-3, 3-4, 4-5, 5-6 and C6-7. MRI right knee showing tear meniscus with effusion.

On examination: the patient is limping. Romberg stance is stable, but cannot elevate the right upper limb due to partial frozen right shoulder. Both quadriceps femores are weak  right -4/5 left 4/5. Dorsiflexion right foot -4/5 and left foot 3/5.

The patient was sent for further investigations, which revealed the presence of intradural mass at the level L1 down to L4 in the conus medullaris with stenosis at these levels. Dorsal MRI was normal and MRI brain showed old scattered lacunar infarctions both cerebral hemispheres more the left side. Bone scan showed only active site at the right shoulder. Right shoulder MRI showed synovitis with partial tear of the supraspinatus. CT-scan of the chest was free.

It was explained to the patient before the surgery, that decompression is needed, but concerning the presence of tumor, it was suggested that some patients have abnormal cauda equina superlonga, that could mimic a tumor when stenosis have place.

Decompressive laminectomy of L2-3 and partial of L1 and L4. There was severe elements of lumbar canal stenosis with absent epidural fat. The patient was positioned with head down to prevent CSF leak. The dura was opened 30 mm along the most suspected tumor location as reported by the radiologist. There in no tumor, no seeders, no inflammatory changes. The roots are tortuous, long and normal looking. Inspection was proceeded entirely between the roots and no data support the presence of vascular malformation. The dura was water-tightly closed with 6 zero nylon.

Routine closure of the wound.  Smooth postoperative recovery .

The patient is looking well and the patient with metastasis usually looking toxic. It is rare to see with localized intradural seeders without the presence of primary tumor, which is usually the posterior fossa in children.

Anatomical variations of the conus medullaris could be variable, among them the super long roots, which become tortuous and with presence of stenosis mimic the presence of intradural masses at the cauda equina and below.

For more information about the superlong roots of the cauda equina press here!