non - hodgkin 's lymphoma is known to involve the central nervous system either primarily or by secondary spread , which tends to occur as part of widespread dissemination late in the disease9 ) . spinal cord compression is reported in up to 10.2% of non - hodgkin 's lymphoma patients , who often have an aggressive form of the disease79111516 ) . it is reported that malignant lymphoma limited to the spinal epidural space is an uncommon initial presentation and participates up to 3.3% of all lymphomas and 9% of epidural spinal tumors17 ) . the sacral spinal epidural space is an uncommon site for primary malignant lymphomas , presenting with symptoms associated with cauda equina compression12 ) . the mid - thoracic spine is the most common site of involvement followed by the lumbar spine and the cervical spine12 ) . we present a rare case of 29-year - old male with sacral spinal epidural malignant lymphoma , which on initial clinical and radiological examination was suggestive of an epidural tumor . a 29-year - old , immunocompetent male was admitted with a 7-day history of pain in the left lower limb . he described the pain as aching in nature and radiating from the buttocks to the calf . the pain was aggravated by lying in the left lateral position , walking , and bending forward but was relieved by lying in the right lateral position . magnetic resonance imaging ( mri ) with contrast showed a well - defined extradural mass lesion that was 5.72.11.8 cm in size at the mid l5 to mid s2 level ( fig . 1 , 2 , 3 ) . the lesion was iso- to hypointense on t1 and t2 weighted images and showed homogenous enhancement and a focal enhancement in the l5 vertebral body on post - contrast images . intra - operatively , the lesion was extradural and not densely adherent to the dura ; the lesion was friable , not firm , fleshy , brownish and hypervascular . on histopathologic examination , the mass was described as an ill - defined , infiltrative lesion composed of heavy lymphoid infiltration with variable - sized lymphoid follicle formations ( fig . the follicular dendritic cells were cd21 positive , and the follicles were positive for bcl-2 ( fig . subsequently , the patient was worked up for systemic disease with mri of the brain and positron emission tomography computed tomography , both of which were normal . he received 6 cycles of chemotherapy with rituximab , cyclophosphamide , doxorubicin , vincristine and prednisolone ( r - chop ) regimen . non - hodgkin 's lymphoma is an uncommon disease involving the spinal epidural space3 ) . only 9% of spinal epidural tumors are lymphomas , with the thoracic spine ( 69% ) being the most common site followed by the lumbar ( 27% ) and cervical spine ( 4%)17 ) . another study reported that only 4% of spinal epidural lymphoma was developed at lumbo - sacral area14 ) . follicular lymphoma is the second most common type of lymphoma in the united states and europe , accounting for approximately 20% of all non - hodgkin 's lymphoma ; however , this type of lymphoma is reported to be relatively rare in korea10 ) . although follicular lymphoma is a lymph node - based lymphoma , it commonly disseminates to the extranodal sites . however , follicular lymphoma which occurs at extranodal sites as a primary lesion is uncommon458 ) . it is reported to be 0.8 - 2.8% which forms epidural tumor primarily among malignant lymphomas6 ) . he was a 70-year - old patient with localized disease to the thoracic spinal cord . a slight male predominance is known for follicular lymphomas ; a male - to - female ratio of 1.6:112 ) . histologically , follicular lymphoma was considered because of the positivity of bcl-2 in follicles in contrast to the bcl-2 negativity in reactive follicles . several studies reported that the mri findings reveal an iso / hypointense lesion on both t1/t2 weighted images and homogenous enhancement on post contrast images extending over multiple vertebrae1213 ) . the patient in this case report had a similar lesion on mri . on the aspect of management of spinal epidural lymphoma , several studies suggest that patients with features of spinal cord or cauda equina compression require to be treated with surgery for the purpose of both tissue diagnosis and decompression12 ) . aabo et al , have reported no difference in outcome between patients undergoing decompressive laminectomy and radiotherapy vs. those receiving spinal radiation only1 ) . patients with primary epidural non - hodgkin 's lymphoma who presented paraplegia of recent onset and underwent decompressive laminectomy showed significant neurological improvement . meanwhile , surgery alone is reported not to be effective at patients ' median overall survival6 ) . the researchers thus suggest that the combination therapy of surgical and non - surgical treatment such as radiotherapy and/or chemotherapy should be done6 ) . here , we have performed an l5-s2 decompressive laminectomy with subtotal lesion excision with significant neurological improvement . chemotherapy was followed with r - chop regimen , which led the patient as complete remission of the disease . the prognosis of primary spinal extradural non - hodgkin 's lymphoma with aggressive histological types is known to be poor in patients > 50 years of age12 ) . however , in young patients , long - term survival is favorable when they underwent surgical decompression followed by chemotherapy and radiotherapy . the overall mean survival period of patients is 8 - 9 months with less than 10% surviving one year16 ) . even though the primary spinal epidural non - hodgkin 's lymphoma is a very rare disease which occur at only 9% of the epidural spinal tumor , clinicians should take it into consideration in the differential diagnosis of patients presenting with back pain secondary to spinal cord or cauda equina compression . we hereby report a rare case of the primary spinal epidural non - hodgkin 's lymphoma occurred at the sacral level .
the sacral spinal epidural space is an uncommon site for primary malignant lymphomas , presenting with symptoms associated with cauda equina compression . 
 especially , lumbo - sacral epidural lymphoma has been reported to be very rare . 
 we present a rare case of 29-year - old male with sacral spinal epidural malignant lymphoma . 
 the patient complained of tingling sensation in his buttocks that was radiating to his calf . 
 the neurological examination was normal . 
 magnetic resonance imaging ( mri ) with contrast showed a well - defined extradural mass lesion at the mid l5 to mid s2 level . 
 the lesion was iso- to hypointense on t1 and t2 weighted images and showed homogenous enhancement and a focal enhancement in the l5 vertebral body on post - contrast images . 
 the patient underwent a l5-s2 laminectomy and subtotal excision of the lesion . 
 intra - operatively , the lesion was extradural and not densely adherent to the dura ; the lesion was friable , not firm , fleshy , brownish and hypervascular . 
 the histologic diagnosis was grade 2 non - hodgkin 's follicular lymphoma . 
 even though the primary spinal epidural non - hodgkin 's lymphoma is a very rare disease , clinicians should take it into consideration in the differential diagnosis of patients with spinal epidural tumor .