Spinal Adhesive Arachnoiditis Following Surgical Treatment for an Intramedullary Tuberculoma of the Conus Medullaris: A Case Report from Western Mexico

Objectives: Describe a rare case of intramedullary tuberculoma (IMT) complicated by chronic adhesive arachnoiditis (CAA).

Presentation of Case: A 19-year-old woman presented with complaints of weight loss, progressive weakness of both lower limbs, and urinary retention. Neurological examination corroborated the motor dysfunction of the lower limbs, associated with sensory disturbances. Magnetic resonance imaging (MRI) detected a ring-enhancing intramedullary mass that expanded the conus medullaris. A provisional diagnosis of neoplastic origin lesion was made and the patient received complete resection of the mass. Histopathology was consistent with tuberculoma. 8 months after beginning postoperative antituberculous therapy, neurological symptoms worsened and follow-up MRI showed a distorted spinal cord with arachnoid cysts and septations, findings that corresponded to CAA. Despite a new surgical intervention, the patient remained with lasting disability.

Discussion: IMT is an uncommon presentation of spine tuberculosis. The clinical manifestations mimic those of any space-occupying lesion (SOL), and are dependent on the location in the spine, thus a differential diagnosis with neoplastic, inflammatory, and other granulomatous lesions is required. Being IMT an encapsulated lesion, it is unexpected that the inflammatory response extends to pia-arachnoid layers conducting to complications, such as CAA. The association between IMT and CAA must be recognized, since it undermines the outcomes of therapeutical interventions.

Conclusion: The diagnosis of IMT complicated by CAA is challenging due to its low frequency. Therefore, this report emphasizes the importance of recognizing the clinical and radiological features of this association to allow an early diagnosis, and facilitate the selection of therapeutic interventions.