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This case study details a 70-year-old woman with severe back pain, revealing elevated cerebrospinal fluid (CSF) protein and lymphocytes. Treatment involved T6 laminectomy, glucocorticoids, and rituximab for an undiagnosed spinal condition.

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Area of Science:

  • Neurology
  • Oncology
  • Immunology

Background:

  • A 70-year-old woman presented with severe, progressive midback pain unresponsive to conventional analgesics.
  • She had no neurological deficits, fever, or history of trauma, but a family history of ovarian cancer.
  • Initial investigations ruled out infection, malignancy, and autoimmune encephalopathy.

Purpose of the Study:

  • To investigate the cause of severe, unexplained midback pain in an elderly patient.
  • To analyze cerebrospinal fluid (CSF) and imaging findings to diagnose the underlying condition.
  • To determine the appropriate treatment strategy for the patient's debilitating symptoms.

Main Methods:

  • Clinical presentation and physical examination.
  • Lumbar puncture with cerebrospinal fluid (CSF) analysis, including protein, glucose, cell count, cytology, flow cytometry, and oligoclonal bands.
  • Imaging studies: CT and MRI of the thoracic spine, CT of the chest, abdomen, and pelvis, and MRI of the brain.
  • Treatment with T6 laminectomy, glucocorticoids, and rituximab.

Main Results:

  • CSF analysis revealed elevated protein (379 mg/dL) and lymphocyte count (94 cells/µL), with mildly decreased glucose.
  • Two oligoclonal bands were detected in CSF, but CSF cytology and flow cytometry showed no evidence of clonal proliferation.
  • Spinal imaging did not reveal a clear cause, while systemic imaging was unremarkable for malignancy.
  • The patient showed improvement following T6 laminectomy and treatment with glucocorticoids and rituximab.

Conclusions:

  • The patient's presentation suggests an inflammatory or lymphoproliferative process affecting the spine, despite negative specific tests.
  • The combination of T6 laminectomy, glucocorticoids, and rituximab was effective in managing her severe back pain.
  • Further investigation may be warranted to fully elucidate the etiology of this spinal condition.