Management Strategies for Osseous Follicular Lymphoma of the Spine

Primary spinal lymphoma accounts for less than 1% of spine tumors. Follicular lymphoma (FL), the most common indolent non-Hodgkin subtype, rarely involves the spine. Its indolent nature may delay diagnosis and require collaborative efforts to address diagnostic ambiguity, structural instability, and treatment. A 33-year-old male was transferred to our center with several months of progressive left leg pain and foot weakness in an L5/S1 distribution. History was notable for a sacral laminectomy four years prior for an epidural lesion diagnosed as a benign calcifying tumor with no subsequent adjuvant therapy or follow-up. Examination revealed mild left dorsiflexion and plantarflexion weakness, with intact rectal tone and sensation. Imaging demonstrated an enhancing lesion involving the L5 vertebral body with epidural extension from L5 to S1. CT-guided biopsy suggested lymphoma and was followed by surgical debulking and stabilization. Final pathology confirmed FL, and the patient received adjuvant bendamustine/rituximab with remission evidenced by resolution of pretreatment hypermetabolic foci on PET-CT with improved leg pain, strength, and absence of active disease at one-year follow-up. This case underscores the clinical and diagnostic challenges of FL. Barriers to timely adjuvant therapy heighten risks and underscore imperatives for multidisciplinary collaboration and close follow-up. Surgeons should typically advocate for biopsy or open surgery for a definitive diagnosis, stabilize fractures when necessary, and integrate oncology and radiation oncology input.