903 - Rare High-Cervical Dumbbell Tumor Presenting as Chronic Occipital Headache: A PM&R-Guided Pathway to Diagnosis and Rehabilitation

Case Diagnosis: Right C1–C2 dumbbell-shaped intra- and extraspinal foraminal mass with significant cervical cord compression. MRI revealed a 2.5-cm heterogeneous extra-axial lesion extending through the C1–2 foramen in classic “dumbbell” configuration, with intra- and extradural components; no other masses or stenosis. Differential favored a C2 nerve-root schwannoma versus meningioma; chordoma was less likely. Clinically, refractory occipital headaches and progressive right axial neck pain with new paresthesias mimicked cervicogenic headache/occipital neuralgia.

Case Description: A 51-year-old woman with two decades of post-traumatic neck pain and headaches presented with worsening right posterior neck pain and first-time right arm numbness. Exam showed occipital tenderness, restricted cervical range of motion (ROM), intact strength, brisk symmetric reflexes, and no long-tract signs. History included Raynaud disease and extensive medication/antibiotic allergies with poor tolerance of analgesics; traction/inversion had provided partial relief. Given red-flag progression, MRI identified the lesion with severe cord mass effect. Physiatry expedited neurosurgical referral; plan was C1–C2 laminotomy/laminectomy with intra/extradural tumor excision. A perioperative rehab/analgesic strategy emphasizing non-opioid multimodal care and tailored medication selection was developed.

Discussions: High-cervical neoplasms are an uncommon but critical masquerader of occipital neuralgia and chronic neck pain. Red-flag features, including progressive pain, paresthesias, and limited ROM, require urgent imaging. The dumbbell configuration strongly suggests nerve-sheath tumor; meningioma remains a differential. PM&R adds value by differentiating tumor from benign pain sources, minimizing delays, coordinating surgical referral, and designing prehabilitation (posture, gentle flexor activation, activity modification) and postoperative care (mobilization, graded ROM, neuropathic-pain strategies, re-imaging triggers).

Conclusions: This case highlights a PM&R-centered pathway to a surgically remediable cervical tumor hidden behind chronic headache. Prompt imaging for red-flag signs, recognition of the C1–C2 dumbbell signature, rapid interdisciplinary coordination, and individualized rehab/analgesic planning optimize outcomes and underscore physiatry’s role in tumor-related spine care.