Challenges in diagnosing malignant lymphoma involving the spine: illustrative cases.

backgroundMalignant lymphoma involving the spinal epidural space is rare and may be difficult to diagnose because its radiological features can mimic more common spinal disorders, including degenerative diseases and spinal epidural hematoma. OBSERVATIONS: Herein, the authors present 2 cases of spinal epidural diffuse large B-cell lymphoma (DLBCL) that were initially suspected to be degenerative spinal disease or spinal epidural hematoma. The patients presented with radiculopathy or acute bilateral lower extremity weakness. Preoperative imaging did not suggest the correct diagnosis. However, surgical exploration unexpectedly revealed epidural soft tissue lesions rather than the presumed degenerative or hemorrhagic pathology. Ultimately, histopathological examination established the diagnosis of DLBCL. Both patients were treated with systemic chemotherapy according to regimens of systemic lymphoma and achieved complete remission. LESSONS: These illustrative cases emphasize the diagnostic challenges associated with spinal epidural lymphoma and the importance of considering malignant lymphoma in the differential diagnosis of atypical epidural lesions. Unexplained vertebral bone signal changes, the presence of longitudinally extensive epidural soft tissues, or imaging findings discordant with the presumed diagnosis may be important diagnostic clues. Early pathological confirmation is essential to prevent diagnostic delay and facilitate the prompt initiation of appropriate treatment. https://thejns.org/doi/10.3171/CASE26632.