A leptomeningeal metastasis revealed by sciatica

Meningeal metastatic disease usually occurs as a complication of a brain tu mor and is exceptionally isolated in patients with solid tumors. We report the case of a 74-year-old woman admitted for mechanical S1 sciatica refract ory to drug therapy. She had been treated for breast cancer three years ear lier. physical findings were pain upon hyperextension of the lumbar spine a nd absence of the ankle jerks. Analysis of cerebrospinal fluid sampled duri ng an intrathecal glucocorticoid injection showed 1 g/L of protein and 11 n ormal cells per mm(3). Grade 3 L5-S1 spondylolisthesis was seen on plain ra diographs, computed tomography scans, and magnetic resonance imaging scans. At that point, the patient developed sphincter dysfunction and motor loss in the left lower limb in the distribution of several nerve roots. Findings were normal from a myelogram and a magnetic resonance imaging study of the brain. A repeat cerebrospinal fluid analysis showed 1.1 g/L of protein and 5 cells/mm(3). Because of the discrepancy between the clinical and imaging study findings, the patient was transferred to a neurology department. A t hird cerebrospinal fluid study showed numerous adenocarcinoma cells, and a repeat magnetic resonance imaging demonstrated a mass in the dural sec oppo site L2. A program of monthly intrathecal methotrexate injections was start ed. A fatal meningeal relapse occurred eight months later. Conclusion, This ease shows that a leptomeningeal metastasis can cause isolated nerve root pain, and demonstrates the diagnostic value of magnetic resonance imaging a nd cerebrospinal fluid cytology in patients with atypical symptoms, particu larly when there is a history of malignant disease.