A 35-year-old mother of one presented with persistent lower back pain that worsened during her second pregnancy, preventing spinal anaesthesia administration. She delivered under general anaesthesia, but one month postpartum, the pain became intolerable. Consulting Dr. Dipak Patel, Senior Neurosurgeon at Zydus Hospital, Ahmedabad, an MRI revealed a tumor at Lumbar 2. Despite no neurological deficits, the patient and family were counselled about risks including malignancy, lower limb weakness, or incomplete removal if the tumor was near nerve roots. Untreated, the tumor could cause paralysis or loss of bowel/bladder control. The decision was made to proceed with surgery.
Surgery and Initial Postoperative Complications
The tumor, measuring 2x1.5 cm and appearing benign, was removed entirely by Dr. Dipak Patel and his team (Dr. Anand Shah, Dr. Ravi Chauhan, Dr. Vandan Raiyani) using intraoperative neuromonitoring (IONM) and a surgical microscope. The surgery proceeded smoothly. However, within four hours of transfer to the ICU, the patient developed epileptic convulsions, lost consciousness, became drowsy, and complained of blurry vision—indicating insufficient blood flow to the visual cortex. Since seizures originate in the brain, a repeat CT scan was performed, revealing intracranial bleeding, a pocket of trapped air, and elevated blood pressure.
Deterioration and Rare Findings
The patient initially stabilized but massively deteriorated the next day, slipping in and out of consciousness. Repeat MRI and CT scans showed new hemorrhages in her brain—an extremely rare finding. Her blood pressure rose sharply, and over the next two days, bleeding spread and intracranial pressure increased. Unable to determine the cause, the team consulted specialists in radiology and neurology (Dr. Dinesh Saini). The patient was placed on ventilator support to manage swelling. She underwent emergency surgery to remove clots and a decompressive craniectomy, where part of the skull bone was deliberately left off to relieve pressure on the swollen brain. Post-surgery, she remained on ventilator support and gradually recovered.
Diagnosis: Paraganglioma and PRES
The treating team suspected the original tumor was a paraganglioma, a rare, highly vascular, and largely benign neuroendocrine tumor that accounts for a small fraction of all spinal tumors. Dr. Dinesh Saini, Neurologist, diagnosed posterior reversible encephalopathy syndrome (PRES), a neurovascular disorder characterized by acute seizures, altered consciousness, headache, and reversible vision loss, typically triggered by rapidly rising blood pressure. Sudden pressure surges overwhelm the brain's autoregulation, breaking down the blood-brain barrier and causing fluid leakage—consistent with the patient's hypertensive spike and visual symptoms.
Expert Commentary and Future Plans
Dr. Dipak Patel remarked, "In nearly four decades of practice, this is among the rarest phenomena I have encountered in a patient. We frequently operate on complex brain and spinal tumor cases, even malignant ones; however, in her case, the precise cause for her complication remains unknown." He added that the patient is scheduled for a cranioplasty in the coming months, where a 3D-printed titanium plate, custom-fitted to her skull, will replace the removed bone flap. The original bone was not reused due to loss of blood supply and infection risk. The lightweight, perforated implant will allow safe drainage of fluids.
Conclusion
This case underscores how rare neurological complications can arise even after successful spinal tumor surgery. Early recognition and expert intervention proved critical in achieving recovery. For more information, visit https://zydushospitals.com.
