Objective: Tremor is classically attributed to abnormalities within supraspinal motor circuits, most commonly the cerebellum, thalamus, red nucleus or basal ganglia and rarely considered a manifestation of spinal cord disease. Limited literature describes abnormal movements in spinal pathology, primarily orthostatic tremor or clonus associated with myelopathy. As a result, tremor as a presenting symptom of a spinal mass is under-recognized, and may delay spinal imaging. We present a case of a spinal cord mass manifesting with a resting tremor that improved after surgical resection.

Background: A 27-year-old man presented to the neurology clinic with a right-hand tremor that had been ongoing for 2–3 years. A prior trial of propranolol provided no benefit. He also reported right-sided occipital numbness. Neurological examination demonstrated a high-frequency, low-amplitude resting tremor predominantly involving the right thumb and index finger. He was hyperreflexic with stimulus induced myoclonus in bilateral upper extremities. There was reduced pinprick sensation in the right C2 dermatome over the occiput. MRI brain was normal, however MRI cervical spine showed a 2.5 × 3.8 × 2.9 cm T2-hyperintense intradural extramedullary mass centered in the right C1–C2 neural foramen, causing remodeling of the foramen and effacement of the adjacent CSF space ;[figure1],[figure2]. CT angiogram demonstrated prominent internal vascularity with multiple feeding vessels arising from the right vertebral artery, which was displaced and partially encased by the tumor; [figure 3]. He was referred to neurosurgery and underwent right C1–C2 decompression with tumor excision, preceded by pre-operative embolization of the right vertebral artery. Histopathological analysis identified a WHO grade I schwannoma. Postoperatively, the course was complicated by a small right lateral medullary infarct. His tremor resolved and occipital neuralgia improved, although some residual deficits from the infarct persisted.

Method: N/A

Results: N/A

Conclusion: While tremor is usually attributed to supratentorial etiologies, this report highlights the need to consider spinal pathology in patients presenting with unexplained/treatment-refractory tremor, especially when accompanied by sensory/reflex abnormalities. Resolution of tremor following tumor resection further supports a causal relationship. Increased recognition of this rare presentation may help reduce diagnostic delays.

figure 1: T2 MRI cervical spine saggital

figure 2: T2 MRI cervical spine axial

figure 3: Ct angiogram coronal

References: Sung, Y.-H., Park, K.-H., Lee, Y.-B., Park, H.-M., & Shin, D.-J. (2010). A case of action-induced clonus that mimicked action tremors and was associated with cervical schwannoma. Journal of Movement Disorders, 3(2), 48–50. https://doi.org/10.14802/jmd.10013

Lv, H., Song, C., Li, W., & Liu, Y. (2022). Orthostatic tremor secondary to primary malignant melanoma of the spinal cord: A case report. European Journal of Neurology, 29(3), 942–946. https://doi.org/10.1111/ene.15208

Pérez-López, C., et al. (2020). [Article on tremor associated with spinal pathology]. [Journal name]. https://pubmed.ncbi.nlm.nih.gov/31917309/

Kim, H., et al. (2012). Symptomatic orthostatic tremor with progressive cognitive impairment in spinal cord lesions. Clinical Neurology and Neurosurgery, 114(10), 1329–1331. https://doi.org/10.1016/j.clineuro.2012.03.021

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MDS Abstracts - https://www.mdsabstracts.org/abstract/beyond-the-brain-resting-tremor-as-a-presentation-of-cervical-spinal-schwannoma/