• History & Physical: This 51-year-old female presented with a two month history of left scapular and neck pain with diffuse left upper extremity numbness. Although she had some initial relief when treated with steroids, her symptoms progressively worsened especially with neck flexion. She has been diagnosed with multiple sclerosis and has recovered fully from an episode of optic neuritis six years ago. Physical examination noted full strength to single muscle testing, with no local sensory deficits. Deep tendon reflexes were brisk and symmetric and Hoffman's negative.

    Imaging: MRI scanning revealed a left T1-T2 mass.

    Figure 1.

    Figure 2.

    Figure 3.

    Figure 4.

    1. The diagnosis of this lesion is most likely

    2. The treatment option of choice in this patient is:

    3. The optimal surgical approach to this lesion would be:

    4. The optimal surgical option offered to this patient would be:

    5. Adjunctive treatments offered based on presumptive diagnosis (Question 1) would include:

    6. Please provide any comments or suggestions regarding management of this case:

    "Blood analysis is neccessary, as well as CT of the first and second thoracic vertebra."

    "Would CT scan thru area for bony erosion before surgery; could be tumour"

    "I hope I am correct in the diagnosis!"

    "Long tract findings? That are unrelated to her devic's?"

    "I will suggest a more detailed presentation on the neurophysiological results."

    "Decompressive laminectomy + resection of lesion. Follow up with physical therapy and exercises to rehab muscles around the region."

    "I would resect the lesion, but also would perform a fusion. In my hands, I would favor spinal instrumentation."

    "I question whether symptoms are at all related to this lesion. Would recommend observation both clinically and radiographically and pursue surgery only if more localizing symptoms arise and/or the lesion demonstrates growth that may jeopardize the spinal cord itself."

    "This appears to represent an hnp...it is directly behind the disc space at T1-2. Difficult to approach anteriorly."

    "Can't seem to make the images larger."

    "Most common lesion at the level of the disc space is of course a herniated disk, albeit rare at this level"

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