High-Grade Pancreatic Neuroendocrine Carcinoma Presenting as Dorsal Spinal Cord Compression: A Diagnostic and Surgical Challenge for the Orthopedic Oncologist.

Introduction: Pancreatic neuroendocrine carcinomas are rare, high-grade malignancies accounting for <2% of pancreatic cancers. They frequently metastasize to the liver and lymph nodes, while skeletal involvement is uncommon. Spinal metastasis as the initial manifestation is exceedingly rare and poses a diagnostic challenge, especially for orthopedic surgeons who often encounter such lesions under the suspicion of infection or primary bone tumor. Case Report: A 20-year-old male presented with acute-onset paraparesis and loss of bladder control. Radiographs and magnetic resonance imaging revealed destructive lesions at D1-D2 with epidural compression and additional vertebral deposits. Emergency decompression was done. Histopathology showed sheets of small round cells, and immunohistochemistry demonstrated positivity for Pan-cytokeratin, synaptophysin, CD56, CK20 (dot-like), and a high Ki-67 index (50-60%), confirming high-grade neuroendocrine carcinoma. A whole-body positron emission tomography-computed tomography identified a metabolically active pancreatic tail mass with multiple hepatic, nodal, and skeletal metastases. The patient received four cycles of cisplatin-etoposide, followed by capecitabine and temozolomide for an incomplete response. Post-operative neurological function improved, and the patient remains ambulant with stable disease on serial imaging. Conclusion: Spinal cord compression may exceptionally rarely be the presenting feature of pancreatic neuroendocrine carcinoma. For orthopedic surgeons, early recognition of atypical spinal lesions, timely decompression, and prompt multidisciplinary referral are critical for achieving functional recovery and improving quality of life even in advanced systemic malignancy. High suspicion, tissue diagnosis, and timely decompression are essential for functional preservation.