The patient came to the clinic 07-December-2013 in wheelchair complaining of severe weak upper and lower limbs and inability to walk the last three weeks. During last months of pregnancy got fever in June and July this year with numbness of the left upper limb and blindness left eye. Delivery was 10-August-2013. 10 days later she deteriorated with headache and pain four limbs. The patient was investigated and treated for tb. The last three weeks she became bedridden  and in wheelchair with lost sensation for urination and defecation. MRI of the brain done 01-September-2013 showing lesion in the pineal area. MRI cervical and dorsal done 18-September-2013 of bad quality not informative. MRI dorsal repeated 28-November-2013 showing pachymeningitis of the dorsal spine.

On examination is in wheelchair, vision left eye improved, but still having mild left abducens paresis. There is weak extensors both hands 4/5, triceps both upper limbs 4/5. There is profound hypalgesia below D3 both sides. The right quadriceps femoris 4/5, left 3/5. Knee adductors and adductors 3/5 weaker in the left. Dorsi and planterflexion both feet 3/5. Babinski positive both sides. Loss of urination and defecation control.

MRI of the brain and whole spine with contrast and spectroscopy was done using Skyra magnetom 07-December-2013. The mass occupying the whole quadrigeminal cistern regressed, but there are scattered gliotic changes of the left pulvinar area and small spots at the edges of the tentorium without mass effect. There is pachymeningitis starting from D2 down to D12 with severe compression of the spinal cord at D8 down to D12. Spectroscopy ruled out malignancy.

The patient was admitted 08-December-2013 and one unit of blood was given and infection specialist started treatment.

Inomed ISIS IOM was attached with dorsal spine tumor protocol. Using C-arm, laminectomy of D8 and D9. There is no epidural fat and no pathologic material out of the dura or the bone structures. The dura was opened and the rubbery like material filling the subarachnoid spaces compressing the spinal cord circumferentially. The layer which was as a carpet with granulomatous lesions was diffusely adherent to the spinal cord. Using sharp dissection it was possible to dissect part of the posterior parts of the pathologic material and it was sent for fresh frozen biopsy. It gave the answer of inflammatory process of unknown character. The granulomatous nodules were decompressed, so as to prevent surgical damage to the spinal cord. Feeding tube No 6 was inserted up to 25 cm and CSF came out and sent for all investigations. There was also debris of the pathologic material which was sent with the excised granulomas for histologic studies.  Using Omipaque myelography was done up and down to see the limits of severe compression. It was decided to extend the dural incision 1 vertebra above and one vertebra down. The dural defect was closed with lyodura to achieve good volume to the spinal cord and surrounding pathologic ring. Water-tight closure of the lyodura with nylon 4 zero. Routine closure of the wound.

Smooth postoperative recovery. The power of the upper limbs became normal and slight improvement of the power of both lower limbs.

This case is very rare. The pathologic material was rubbery strangulating and compressing the spinal cord. Surgical decompression at all layers was mandatory to provide good circulation to the affected spinal cord.

The pathological process was constricting the spinal cord as a band. It was necessary to release this band.