Neoplastic Cauda Equina Syndrome: When Do We Not Operate?

BACKGROUND AND IMPORTANCE: Burkitt lymphoma is a high-grade non-Hodgkin lymphoma that can cause spinal cord compression leading to neurological compromise. Prompt interventions are critical to prevent permanent deficits. Through this case report, we highlight the rapid resolution of acute cauda equina syndrome in an adolescent with Burkitt lymphoma in the setting of tandem spinal cord and cauda equina compression. CLINICAL PRESENTATION: An 18-year-old man developed cervical lymphadenopathy and weight loss 2 months prior and was diagnosed with Burkitt lymphoma 1 month earlier. He developed bilateral lower extremity paresthesias 1 week before presentation, with acute worsening over 24 hours resulting in weakness and urinary overflow incontinence. MRI revealed epidural masses at T5 to T7 causing spinal cord compression and L5/S1, causing severe cauda equina compression. He had left foot weakness, saddle anesthesia, poor rectal tone, and urinary retention, draining more than 1000 mL of urine after Foley catheter insertion. The radiosensitivity of Burkitt lymphoma prompted emergent radiotherapy (800 cGy) within 14 hours of presentation. On postradiation day 1, left foot strength improved, and by day 3, full neurological function, including bladder control, was restored. Repeat MRI on postradiation day 4 showed complete resolution of both epidural masses. He was discharged neurologically intact, requiring no surgical intervention, and continued chemotherapy as planned. CONCLUSION: This case underscores the critical need for the spine surgeon to understand the histology and radiosensitivity of any spinal neoplastic processes. For radiosensitive tumors such as lymphoma, emergent radiation can lead to rapid resolution of neurological deficits without requiring surgery.