Osteoradionecrosis mimicking metastatic epidural spinal cord compression

A 45-year-old man sought treatment for pneumonia and a 2-month history of progressive asymmetrical quadriparesis. Five years earlier, he underwent resection of oropharyngeal squamous cell carcinoma followed by radiotherapy. Cumulative dose was 6,000 cGy to oral cavity and bilateral neck areas, skull base, and anterior vertebral bodies. No chemotherapy was administered. On physical examination, he was cachectic without lymphadenopathy or visible lesions in the floor of the mouth and oropharynx. Neurologic examination revealed a decreased gag reflex and left accessory nerve palsy. Power was 0 to 1 of 5 in the left upper extremity and 3 of 5 in the left lower extremity. Power on the right side was 4 of 5. He was nonambulatory. Tone and reflexes were increased in the left leg, decreased in the left arm, and normal on the right. Sensory examination was intact. MRI revealed a marrow-replacing process involving the clivus and odontoid process and an enhancing 9-mm dural-based mass resulting in compression of the medulla oblongata with T2 signal abnormality extending from the brainstem to C6 to C7 level. A Chiari I malformation was present (figure, A through D). CT demonstrated an irregular, mixed sclerotic …

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