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Case #2

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Expand Physical Exam

04/15/XX

54-year-old female with a history of back pain has new complaints of burning and numbness over abdomen and R leg. She reports stumbling, difficulty with balance and urinary urgency.

Expand X-Rays & Scans

04/18/XX

MRI spine: intramedullary thoracic spinal cord lesion extends from T6-T11.

07/01/XX

Thoracic spine CT: Previously seen cord edema has resolved.

Expand Operative Findings

04/27/XX

Hyperechogenic lesion seen centered in T6 area, epicenter of tumor was identified by ultrasound. The spinal cord was incised with a microknife and a gross total resection of the tumor was achieved.

Expand Pathological Reports

04/27/XX

Intramedullary spinal cord tumor excision – Grade 2 of 4 ependymoma.

Expand Treatment

04/27/XX

Surgery: Bilateral T5-T12 laminectomies/partial facetomies and removal of spinal cord tumor.

05/25/XX

Radiation: Radiation oncology consult: Surgical excision appears complete. Radiation therapy is not recommended at this time. Follow-up with brain/spine MRI in 6 months.