Pinealoma Masquerading as Post-Epidural Spinal Injection Dural Tear/Side Effect in a Patient with Chronic Back Pain

Abstract

Introduction: Pineal gland neoplasms are uncommon, accounting for less than 1% of adult brain tumors. The variable morphology, radiological characteristics, and symptomatic manifestations further complicate the prompt diagnosis and management [1]. Symptoms commonly arise from the tumor’s mass effect with compression of surrounding structures (e.g., headaches, nausea, vomiting, blurry vision, vertigo, fatigue) and may further induce obstructive hydrocephalus and Parinaud’s syndrome [2]. However, with Non-Specific or atypical pinealoma presentation, overlapping medical history suggestive of alternative etiologies may obscure the underlying diagnosis and delay appropriate workup and treatment. Case Presentation: We present a 41-year-old man with a history of chronic lower back pain and lumbar disc herniation presenting with worsening fatigue, cognitive lapses, and gait issues for three to four weeks, as well as nausea, vomiting, and blurry vision for the last three days. One month ago, the patient underwent bilateral L5-S1 transforaminal epidural steroid injection for lumbar radiculopathy and discogenic pain, which resolved the pain. Presentation appeared consistent with dural tear secondary to recent epidural injection. Brain imaging was obtained in the setting of altered mental status and neurologic symptoms. MRI showed a 17mm enhancing pineal mass with associated supratentorial obstructive hydrocephalus, with grade 1 papilledema found on ophthalmologic exam. CT chest/abdomen/pelvis was negative for primary lesions. Six days after initial presentation, the patient underwent an endoscopic third ventriculostomy for pineal tumor biopsy, and CSF collection for hydrocephalus treatment. The patient tolerated the procedure well without complications, was deemed medically and neurologically stable, and was discharged two days post-operatively. He continued to have lapses in judgment, fatigue, and double vision, and underwent a full craniotomy three weeks after discharge, which revealed a vermis lesion. Pathological report revealed a high-grade glioma. Conclusion: Unintentional dural tears occur in 1-3% of epidural spinal injections, commonly presenting as headaches, nausea, vomiting, and dizziness/ataxia [3]. However, this case highlights the need for clinical suspicion of alternative causes for similar presentation and the utility of further workup.