Asymptomatic intraspinal epidermoid cyst in a 7-year-old male with juvenile idiopathic arthritis identified by an advanced physiotherapist practitioner: a case report

ABSTRACT

Background

Pediatric intraspinal epidermoid cysts are rare with potential to cause life-altering outcomes if not addressed. Reports to date describe symptomatic presentations including loss of bladder or bowel function and motor and sensory losses. This case report identifies the diagnostic challenge of an asymptomatic intraspinal epidermoid cyst in the cauda equina region presenting in a 7-year-old male with juvenile idiopathic arthritis (JIA).

Diagnosis

An advanced physiotherapist practitioner assessed and diagnosed a previously healthy 7-year-old-male of South Asian descent with JIA based on persistent knee joint effusions. Complicating factors delayed the investigation of abnormal functional movement patterns, spinal and hip rigidity and severe restriction of straight leg raise, all atypical for JIA. Further delaying the diagnosis was the lack of subjective complaints including no pain, no reported functional deficits, and no neurologic symptoms. A spinal MRI investigation 10-months from initial appointment identified intraspinal epidermoid cysts occupying the cauda equina region requiring urgent referral to neurosurgery.

Discussion

Clinical characteristics and pattern recognition are essential for diagnosing spinal conditions in pediatric populations. Diagnostic challenges present in this case included co-morbidity (JIA), a severe adverse reaction to treatment, a lack of subjective complaints and a very low prevalence of intraspinal epidermoid cysts.

Impact Statements

Early signs of pediatric asymptomatic intraspinal epidermoid cysts included abnormal functional movement patterns, rigidity of spine, severely limited straight leg raise and hip flexion without pain. Advanced physiotherapist practitioners can be integral to pediatric rheumatology teams considering their basic knowledge in musculoskeletal examination and functional mobility assessment when identifying rare spinal conditions that present within the complex context of rheumatic diseases.

KEYWORDS:

• Advanced practice physiotherapy
• case report
• intraspinal epidermoid cyst
• juvenile idiopathic arthritis
• pediatrics

Abrreviations

AE	=	Adverse Event
APP	=	Advanced Physiotherapist Practitioner
CES	=	Cauda Equina Syndrome
ERA	=	Enthesitis Related Arthritis
GI	=	Gastrointestinal
JIA	=	Juvenile Idiopathic Arthritis
MRI	=	Magnetic Resonance Imaging
MRP	=	Most Responsible Physician
MSK	=	Musculoskeletal
NSAID	=	Non-Steroidal Anti-Inflammatory Drug
PtGA	=	Patient Global Assessment
ROM	=	Range of Motion
SIJ	=	Sacroiliac Joint
SLR	=	Straight Leg Raise
TMJ	=	Temporomandibular Joint
VAS	=	Visual Analog Scale

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.

Notes on contributors

Julie Herrington

Julie Herrington, PT, MSc, ACPAC is an advanced physiotherapist practitioner (APP) working in pediatric and young adult rheumatology. She completed her advanced practitioner training through the ACPAC program associated with the University of Toronto. She completed her Research Masters in Rehabilitation Science at McMaster University focusing her research on the impact of the APP role on the health care system.

Michelle Batthish

Michelle Batthish MD, MSc, FRCPC is a pediatric rheumatologist at McMaster Children’s Hospital and Associate Professor of Pediatrics at McMaster University. She completed her fellowship at the Hosptial of Sick Children and has an MSc in Health Services Research from the Institue of Health Policy, Management and Evaluation from the University of Toronto. Her clinical and research interests are in healthcare transition and quality improvement in pediatrc rheumatology.

Heba Takrouri

Heba Takrouri MBBS, is a Pediatric radiologist at McMaster Children’s Hospital and an Associate Professor of Diagnostic Imaging at McMaster University, Hamilton, Ontario.

Blake Yarascavitch

Blake Yarascavitch, MD is a Pediatric neurosurgeon at McMaster Children’s Hospital and an Associate Professor of Surgery in the Faculty of Health Sciences at McMaster University, Hamilton, Ontario.

Anita Gross

Anita Gross, PT, MSc, FCAMPT is an associate clinical professor at McMaster University on the School of Rehabilitation Sciences leading their advanced orthopedic musculoskeletal-manipulative physical therapy (OMPT) program. She is the chair of the Taskforce on Pediatric Manipulation for the World Physiotherapy specialty subgroups IFOMPT and IOPTP, coordinates the Cervical Overview Group research network, and participates in randomised clinical trials on back pain (Welback). She has a special interest in knowledge translation research methodologies. She is a clinician scientist and educator.