Surgical management of a pulmonary neuroendocrine tumor causing epidural spinal cord compression and transdural intramedullary invasion: illustrative case.

Background: Intramedullary spinal cord metastasis from local transdural invasion is an exceedingly rare event. Therefore, specific guidance on the timing, type, and extent of surgical intervention is lacking.

Observations: A 60-year-old male with a known pulmonary neuroendocrine tumor presented with 2 days of progressive lower extremity paraplegia rendering him nonambulatory. MRI demonstrated transpleural and paravertebral invasion by the mass with extension through the left T1-2 and T2-3 neural foramina causing significant epidural compression. There was also transdural invasion at T2 extending intramedullary to the C4 spinal level, with associated cord edema. He underwent posterior cervicothoracic laminectomy and fusion with transpedicular epidural tumor debulking. The intramedullary component was not removed. He received adjuvant radiation therapy and chemotherapy and at the 6-month follow-up demonstrated significant return of motor function in his lower extremities, ambulating with a walker.

Lessons: This case illustrates that rapid surgical decompression can still provide benefit even for aggressive tumors causing transdural and intramedullary invasion. The decision on whether to remove the intramedullary component should be made on a case-by-case basis and guided by the patient's neurological examination in combination with imaging findings. https://thejns.org/doi/10.3171/CASE25200.