Extramedullary intradural spinal tumors: a review of modern diagnostic and treatment options and a report of a series

Single-Center Experience of Resection of 120 Cases of Intradural Spinal Tumors

BACKGROUND

Our study presents a single-center experience of resection of intradural spinal tumors either with or without using intraoperative computed tomography-based registration and microscope-based augmented reality (AR). Microscope-based AR was recently described for improved orientation in the operative field in spine surgery, using superimposed images of segmented structures of interest in a two-dimensional or three-dimensional mode.

METHODS

All patients who underwent surgery for resection of intradural spinal tumors at our department were retrospectively included in the study. Clinical outcomes in terms of postoperative neurologic deficits and complications were evaluated, as well as neuroradiologic outcomes for tumor remnants and recurrence.

RESULTS

112 patients (57 female, 55 male; median age 55.8 ± 17.8 years) who underwent 120 surgeries for resection of intradural spinal tumors with the use of intraoperative neuromonitoring were included in the study, with a median follow-up of 39 ± 34.4 months. Nine patients died during the follow-up for reasons unrelated to surgery. The most common tumors were meningioma (n = 41), schwannoma (n = 37), myopapillary ependymomas (n = 12), ependymomas (n = 10), and others (20). Tumors were in the thoracic spine (n = 46), lumbar spine (n = 39), cervical spine (n = 32), lumbosacral spine (n = 1), thoracic and lumbar spine (n = 1), and 1 tumor in the cervical, thoracic, and lumbar spine. Four biopsies were performed, 10 partial resections, 13 subtotal resections, and 93 gross total resections. Laminectomy was the common approach. In 79 cases, patients experienced neurologic deficits before surgery, with ataxia and paraparesis as the most common ones. After surgery, 67 patients were unchanged, 49 improved and 4 worsened. Operative time, extent of resection, clinical outcome, and complication rate did not differ between the AR and non-AR groups. However, the use of AR improved orientation in the operative field by identification of important neurovascular structures.

CONCLUSIONS

High rates of gross total resection with favorable neurologic outcomes in most patients as well as low recurrence rates with comparable complication rates were noted in our single-center experience. AR improved intraoperative orientation and increased surgeons' comfort by enabling early identification of important anatomic structures; however, clinical and radiologic outcomes did not differ, when AR was not used.

Primary intradural Extraosseous Ewing's sarcoma of the cauda equina: A case report and literature review

Intradural Extraosseous Ewing sarcoma (IEES) is an infrequent occurrence. We report a case of a 66-year-old male who presented with a 2-month history of low back pain and bilateral S1 sciatica, with acute sphincter dysfunction. Imaging studies revealed an intradural extramedullary lesion in the cauda equina spanning from level L4 to S1. The patient underwent partial removal of the intradural lesion. Histopathological examination showed the presence of small round cells, which were consistent with Ewing Sarcoma. The patient was then treated with targeted radiation therapy and chemotherapy. The rarity of IEES in this specific location underscores the significance of evaluating and managing patients with intradural spinal tumors with careful consideration of this diagnosis. To further investigate this condition, we conducted a thorough review of the literature on IEES involving the lumbar spine and cauda equina. Our analysis revealed that patients with this condition frequently exhibit rapidly progressive neurological symptoms likely attributed to hemorrhagic transformation. This characteristic may serve as a distinguishing factor from other lesion types, particularly benign ones. Our study provides a comprehensive summary that can offer direction for clinical management in comparable uncommon and novel cases.

A rare case of atypical intradural extramedullary glioblastoma diagnosed utilizing next-generation sequencing and methylation profiling: illustrative case

BACKGROUND

Primary spinal cord tumors, especially primary spinal cord glioblastoma multiforme (PSC-GBM), are exceptionally rare, accounting for less than 1.5% of all spinal tumors. Their infrequency and aggressive yet atypical presentation make diagnosis challenging. In uncertain cases, a surgical approach for tissue diagnosis is often optimal.

OBSERVATIONS

A 76-year-old male presented with a rapidly progressing clinical history marked by worsening extremity weakness, urinary retention, and periodic fecal incontinence alongside diffuse changes on neuraxis imaging. The patient, in whom subacute polyneuropathy was initially diagnosed, received multiple rounds of steroids and intravenous immunoglobulin without clinical improvement. Histopathological review of the biopsy tissue yielded an initial diagnosis of spindle cell neoplasm. Next-generation sequencing (NGS) is done routinely on all neuropathology specimens at the authors' institution, and methylation profiling is pursued in difficult cases. Ultimately, NGS and methylation profiling results were essential to an integrated final diagnosis of GBM.

LESSONS

PSC-GBM is a rare but highly aggressive occurrence of this tumor. Prolonged back pain, rapid neurological decline, and imaging changes warrant the consideration of lesional biopsy for precise disease characterization. In inconclusive cases, NGS has proved invaluable for clinical clarification and diagnosis, underscoring its importance for integrated diagnoses in guiding appropriate treatment strategies.

Common differential diagnosis of low back pain in contemporary medical practice: a narrative review

With a wide range of etiologies, low back pain (LBP) presents a true clinical challenge, finding its origins both in intrinsic spinal and systemic conditions, as well as referred ones. This review categorizes the LBP into these three groups and aims to offer a comprehensive look at the tools required to diagnose and differentiate them. The intrinsic etiologies are based on conditions that affect the musculoskeletal components of the lumbar spine, such as intervertebral disc disease, stenosis, muscular imbalance, and facet joint degeneration. The systemic causes usually extend beyond local structures. Such are the cases of neoplasia, infections, and chronic inflammation. The diagnosis is rendered even more complex by adding the referred pain, which only manifests in the lower back yet arises in more distant locations. By synthesizing the literature that encompasses the problem, this review aims to augment the understanding of the differential diagnoses of LBP by showcasing the subject's nuances. This categorization provides a structured approach to a patient-centered diagnosis, which could facilitate the medical practitioners' efforts to navigate this pathology more effectively.

Predictors of Neurological Worsening after Resection of Spinal Meningiomas

BACKGROUND

Due to the slow-growing nature of spinal meningiomas, they are mostly asymptomatic for a long time, and become symptomatic after the compression of the spinal cord or nerve roots. The aim of this study was to identify predictors for a poor clinical outcome after the surgical resection of spinal meningiomas and thereby to allow a preoperative identification of high-risk spinal meningiomas.

METHODS

Data acquisition was conducted as a single-center retrospective analysis. From 1 January 2004 to 31 December 2019, 121 patients who underwent surgical resection of a spinal meningioma were reviewed. Clinical and radiological data (such as tumor size, location, occupation ratio of the spinal canal, and the degree of spinal cord compression) were assessed. The functional clinical findings of the patients were recorded using the Karnofsky Performance Score, modified McCormick scale, and Frankel scale preoperatively, at discharge, and 3-6 months after surgery.

RESULTS

The mean patient age was 66 ± 13 years. A total of 104 (86%) patients were female and 17 (14%) were male. The thoracic spine (68%) was the most common location, followed by the cervical (29%) and lumbar (3%) spine. Preoperatively, 11.7% of patients were categorized as McCormick 1, 35.8% as 2, 39.2% as 3, 11.7% as 4, and 1.7% as 5. The neurological function of the patients with a functional deficit prior to surgery improved in 46% of the patients, remained unchanged in 52%, and worsened in 2% at discharge. At early follow-up, the proportions were 54%, 28%, and 5%, respectively. Preoperative Frankel scale was a significant predictor of a postoperative deterioration. Patients with Frankel score A to C preoperatively had a 9.2 times higher chance of clinical deterioration postoperatively (OR = 9.16). We found that the Frankel scale weakly correlated with the degree of spinal cord compression. In this study, other radiological parameters, such as the degree of cord compression and spinal canal occupation ratio, did not show a significant effect on the outcome.

CONCLUSIONS

Surgery of intraspinal meningiomas can be considered safe. Neurological function improves in a large proportion of patients after surgery. However, a relevant preoperative deficit according to the Frankel scale (grade A-C) was a significant predictor of a postoperative neurological deterioration.

Schwannomas Mimicking Leptomeningeal Spread in the Setting of Breast Cancer: A Case Report

BACKGROUND

Breast cancer is currently the most diagnosed cancer globally. For patients who complete breast cancer treatment, developing a survivorship plan is important, including serial history, physical examinations, and annual mammograms to look for recurrence and metastasis.

CASE REPORT

This is a case report of a 76-year-old female with a history of recurrent breast cancer who presented with lower-back pain and found to have MRI findings initially concerning for intradural extramedullary metastatic disease. Biopsy was later found to be consistent with benign spinal schwannomas.

CONCLUSION

We present a unique case of spinal masses in the setting of breast cancer initially concerning for leptomeningeal spread, later found to have benign schwannomas that mimicked leptomeningeal spread on imaging. To our knowledge, this is the first reported case of schwannomas mimicking leptomeningeal spread in a patient with a history of recurrent breast cancer. After metastasis is excluded, schwannomas should be considered in the differential of benign spinal lesions.

Clinical diagnostic and radiographic features of a primary intradural spinal chondrosarcoma in a young adult: illustrative case

BACKGROUND

Mesenchymal chondrosarcoma (MCS) is an aggressive subtype of chondrosarcoma that occurs extremely rarely in the central nervous system. Patients often present with pain or sensorimotor deficits, and resection is considered the gold standard. The role of adjuvant radiation and/or chemotherapy is largely unknown.

OBSERVATIONS

A 22-year-old male presented with a 4-month history of progressive back and bilateral leg pain. He underwent imaging workup with magnetic resonance imaging of the lumbar spine and was found to have an intradural, extramedullary, heterogeneously enhancing mass spanning the L4-5 vertebral levels. Intraoperatively, a lobular, partially calcified mass with a ventral dural attachment displacing the nerve roots laterally was observed. The mass was removed en bloc, and the patient later underwent adjuvant radiotherapy, with no evidence of recurrence 2 years following surgery.

LESSONS

Spinal MCS is extremely rare and often presents with a more aggressive course than conventional chondrosarcoma. Radiological diagnosis is challenging, as the tumor mimics different pathologies. The presence of calcifications, heterogeneous enhancement, and a more rapid clinical course as well as the presence of HEY1::NCOA2 gene fusion, which can be detected by surrogate immunohistochemistry, aids in diagnosis. Resection is the standard of care, and adjuvant radiation may be considered to reduce local recurrence, although further studies are warranted.

Factors Related to the Deterioration of Postoperative Lower Back Pain in Hemilaminectomy Approach for Lumbar Spinal Schwannoma Resection

Objective

This study aimed to explore the related risk factors in patients who underwent hemilaminectomy for lumbar spinal schwannoma resection and who experienced deterioration of postoperative lower back pain in comparison to preoperative pain levels.

Methods

This retrospective study recruited 61 patients from the First Affiliated Hospital of An Hui Medical University between January 2018 and June 2019. All data were collected from clinical records and analyzed at 1-month and at 1-year follow-up. The visual analog scale (VAS) was used to evaluate pain, and neurologic function was assessed using the Modified McCormick Scale. Intraoperative neurophysiological monitoring was used to assess neuronal integrity and mitigate injury. Statistical analysis of the data was performed using the SPSS version 19 software.

Results

Preoperative pain improved dramatically in the 1-year follow-up (VAS: preoperative, 3.84±2.19; 1-year follow-up, 2.13±2.26; P<0.001). The pain-improved group and worsened group showed a significant difference at 1-month (VAS: 1.76±1.56; 5.54±1.26; P<0.05) and at 1-year (VAS: 0.83±1.09; 4.80±1.58; P<0.05) follow-up. The pain-improved and worsened groups had a significant difference in tumor size and hemilaminectomy removal segments at 1-month and 1-year follow-up, but A-train occurrence on electromyography could only be seen as a statistical difference in the 1-month follow-up. Logistic regression analysis revealed that tumor size was an independent risk factor for postoperative lower back pain deterioration.

Conclusion

The hemilaminectomy approach is a safe and effective method that can dramatically relieve pain in spinal lumbar schwannoma resection. Tumor size is an independent risk factor for postoperative lower back pain. A-train on spontaneous electromyography has been shown to be a reliable predictive factor for the evaluation of postoperative lower back pain. However, further detailed analysis of A-train characteristics can provide a more accurate warning during surgery.

Adult cervicothoracic subpial fibrolipoma without dysraphism: An extremely rare case report

INTRODUCTION

Spinal tumors constitute 15 % of all tumors in the central nervous system. Pain is often the initial symptom, which can be localized, nocturnal, or radiated to the arms and/or limbs. We report a rare case with a subpial lipoma in the cervicothoracic spine and review the current literature.

CASE PRESENTATION

A 22-year-old female presented with the chief complaint of tetraparesis for three months before admission. Magnetic resonance imaging revealed an intradural tumor on the fifth cervical to fourth thoracic vertebrae. She underwent a laminectomy to remove the tumor completely. Histopathological examination revealed a proliferation of mature fat cells amongst fibrous connective tissue. Surrounding nerve fibers and erythrocyte-filled blood vessels were also found, suggesting a subpial fibrolipoma. Postoperatively, there was an improvement in muscle strength six weeks after surgery. Motoric strength was grade 5 for the upper extremities and grade 4 for the lower extremities.

DISCUSSION

In this patient, cervicothoracic laminectomy and tumor removal were performed without instrumentation. Total tumor resection is the primary goal when removing a pathological lesion. However, this depends on the lesion's adhesion to the surrounding tissue. Therefore, partial tumor resection may be possible, given the neurological complications that can occur.

CONCLUSION

Because subpial lipomas are rare, their treatment is highly specialized. An assessment of the patient's physical condition and imaging assessments can provide information about potential treatment strategies and outcomes.

The Role of Nanotechnology in Spinal Cord Tumors

The efficacy of current multimodal therapeutic strategies in spinal cord tumors is limited by the lack of specific therapies. Importantly, sufficient amount of therapeutic materials should be concentrated in tumors in order to be efficient. Overcoming the blood-brain barrier is the major obstacle for chemotherapeutics, which cannot reach the tumor bed in efficacious doses. The intrinsic properties of nanoparticles make them suitable for activating numerous processes both at the cellular and subcellular levels, making them good candidates to be used for different purposes in medicine. Furthermore, the adaptability characteristic of NPs may enable them to pass through the blood-brain barrier and transport different pharmacological compounds. Nanoparticle systems provide prolonged drug delivery directly to the tumor or by functionalizing the material surface with peptides and ligands allowing the drug-loaded material to specifically target the tumor cells. In this chapter, various preclinical and/or clinical studies in treatment of spinal cord tumors are discussed.

Spinal Intradural Extramedullary Tumors: A Retrospective Analysis on Ten-Years' Experience of Minimally Invasive Surgery and a Comparison with the Open Approach

Spinal intradural extramedullary (ID-EM) tumors are pathologies widely treated through a classical open approach. However, minimally invasive surgery is gaining traction as a comparable treatment option because it carries less morbidity and may reduce healthcare costs.This study aimed to compare the clinical and functional outcomes of open versus minimally invasive approaches for patients with ID-EM tumors. We performed a retrospective analysis on prospectively collected data from patients with ID-EM tumors submitted to surgery. Baseline features and operative variables were compared, including surgery duration and estimated blood loss (EBL). Postoperative data covered tumor histology, length of stay (LOS), complication(s), and neurological status (Medical Research Council (MRC) scale) at the last follow-up.In total, 46 patients were included: 30 (65.2%) operated through an open approach and 16 (34.8%) through a minimally invasive surgical (MIS) approach. The predominant histology type was schwannomas (43.5%). Lesions more frequently affected the lumbar spine (34.8%). The tumor dimensions were similar in both cohorts. The minimally invasive approach was on average 76.7 min faster and correlated positively with less EBL (140 mL less than that of the open approach). Patients in the MIS group had shorter LOSs (5.63 days vs. 17.27 days) and had fewer postoperative complications. No significant difference in functional outcome was found.MIS is as effective as the traditional approach in achieving comparable functional outcomes, with advantages such as shorter surgery durations, less blood loss, and shorter hospital LOSs.

Characterization and Treatment of Spinal Tumors

The prevalence of spinal tumors is rare in comparison to brain tumors which encompass most central nervous system tumors. Tumors of the spine can be divided into primary and metastatic tumors with the latter being the most common presentation. Primary tumors are subdivided based on their location on the spinal column and in the spinal cord into intramedullary, intradural extramedullary, and primary bone tumors. Back pain is a common presentation in spine cancer patients; however, other radicular pain may be present. Magnetic resonance imaging (MRI) is the imaging modality of choice for intradural extramedullary and intramedullary tumors. Plain radiographs are used in the initial diagnosis of primary bone tumors while Computed tomography (CT) and MRI may often be necessary for further characterization. Complete surgical resection is the treatment of choice for spinal tumors and may be curative for well circumscribed lesions. However, intralesional resection along with adjuvant radiation and chemotherapy can be indicated for patients that would experience increased morbidity from damage to nearby neurological structures caused by resection with wide margins. Even with the current treatment options, the prognosis for aggressive spinal cancer remains poor. Advances in novel treatments including molecular targeting, immunotherapy and stem cell therapy provide the potential for greater control of malignant and metastatic tumors of the spine.

Unusual patterns of tuberculosis on cross-sectional imaging: a pictorial review

Background

Tuberculosis is routinely encountered on imaging throughout the world. Radiologists are usually familiar with the common patterns of tuberculosis on cross-sectional imaging. However, tuberculosis frequently presents with unfamiliar imaging patterns and/or uncommon anatomic sites which still pose a diagnostic challenge.

Discussion

Rapid improvements in the management of acquired immunodeficiency syndrome patients leading to increased survival as well as advances in chemotherapy and immunosuppressive medication have complicated the presentation of tuberculosis by increasing the probability of unconventional sites and patterns of involvement in tuberculosis leading to unfamiliar imaging appearances. In this review, we describe these unfamiliar imaging patterns of tuberculosis and provide a diagnostic protocol for arriving at the right diagnosis and differentiating these from other pathologies with similar imaging appearances. These are described through case-based illustrations of unusual patterns and anatomic locations of tuberculosis.

Conclusions

It is important for radiologists to be aware of such unusual imaging patterns of tuberculosis in order to facilitate early and accurate diagnosis for appropriate patient management in the face of changing patient demographics and pathological profile of tuberculosis in the current era of scientific advancements.

Prediction of Discharge Status and Readmissions after Resection of Intradural Spinal Tumors

Objective

Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors.

Methods

IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset.

Results

A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n=5,023, 99.3%) and tumors were most commonly found in the thoracic region (n=1,941, 38.4%), followed by the lumbar (n=1,781, 35.2%) and cervical (n=1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%).

Conclusion

Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

Comparison of Neuroendoscopic and Microscopic Surgery for Unilateral Hemilaminectomy: Experience of a Single Institution

Objective

This study was designed to compare the safety and efficacy of unilateral hemilaminectomy conducted under complete neuroendoscopic visualization (UHNV) relative to unilateral hemilaminectomy under total microscopic visualization (UHMV) for the treatment of patients diagnosed with intraspinal tumors.

Methods

In total, 41 patients undergoing intraspinal tumor resection at Northern Jiangsu People's Hospital were included in this study, including 20 and 21 patients in the UHNV and UHMV groups, respectively. Intraoperative parameters including incision length, operative duration, number of vertebral laminae removed and intraoperative blood loss, as well as indicators of curative efficacy such as total tumor resection rates and postoperative symptom improvement rates, and safety indicators including complication rates, recurrence rates, spinal deformity rates, spinal instability incidence, and length of stay (LOS), were compared between the two groups.

Results

In contrast to the UHMV group, patients in the UHNV group had a significantly shorter incision length and decreased intraoperative blood loss (P < 0.05), while the operative duration (P > 0.05) showed no statistical difference. Although the postoperative improvement and total tumor resection rates were enhanced, the difference was not statistically significant (P > 0.05). In comparison, the bedridden time and length of stay (LOS) were significantly shortened (P < 0.05) in the UHNV group. However, there were no significant differences in recurrence, incidence of complications, spinal deformity, and spinal instability (P > 0.05).

Conclusion

Collectively, our findings indicate that UHNV is not inferior to the UHMV approach. Moreover, due to its safe and minimally invasive nature, UHNV represents a promising alternative to UHMV as a treatment for patients with intradural extramedullary tumors.

Monitoring spinal surgery for extramedullary tumors and fractures

Meningiomas are the most common intradural extramedullary tumors, followed by nerve sheath tumors that can also grow extradurally. Metastases are the most frequent extradural tumors and most commonly affect the thoracic vertebrae. Spinal fractures with column dislocation and/or instability require surgical fixation. Spine surgery for an extramedullary tumor or fracture usually involves decompression of neural elements and instrumentation for stabilization. These procedures risk spinal cord and nerve root injury. The incidence of nerve root deficits after resection of nerve sheath tumors is particularly high since the tumor grows from the rootlets. Intraoperative neurophysiologic monitoring and mapping techniques have been introduced to prevent iatrogenic neurologic deficits. These include motor and sensory evoked potentials, electromyography, compound muscle action potentials, and the bulbocavernosus reflex. The combination of techniques chosen for a particular procedure depends on the surgical level and the character of the lesion.

Expression of Progesterone Receptor and Its Association with Clinicopathological Characteristics in Meningiomas: A Cross-Sectional Study

BACKGROUND

Meningiomas that are progesterone receptor positive have a low recurrence rate and good prognosis compared to those that are progesterone receptor negative. This study aimed to determine the prevalence of expression of progesterone in meningiomas and its association with clinicopathological characteristics.

MATERIALS AND METHODS

This was a cross-sectional laboratory-based study that was conducted at Muhimbili National Hospital. The study included 112 formalin-fixed paraffin-embedded tissue blocks of patients who were confirmed to have meningiomas on histological basis from January 2010 to December 2014. Immunohistochemical expression of progesterone receptor was tested using a primary monoclonal progesterone receptor antibody ready to use (IR 068 Dako). The χ2 test was used to determine the association between clinicopathological characteristics and progesterone receptor expression. A 2-tailed P < 0.05 was considered significant.

RESULTS

The mean age of the patients was 45.5 ± 3.601 years, and majority (66.1%, n = 74) were in the age group between 31 and 60 years. Also, majority of the patients (60%, n = 67) in this study were females. Over one-third of the cases (34.8%, n = 39) comprised of meningotheliomatous subtype, and majority of the cases (89.3%, n = 100) were of grade I. The prevalence of progesterone expression was 54.5% (n = 61), and only age was associated with progesterone receptor expression (P = 0.043).

CONCLUSION

The finding of high expression of the progesterone receptor for grade I cases in this study indicates that progesterone receptor expression in meningiomas is of prognostic value and may be considered when evaluating patients for management. Lack of expression of progesterone receptor in all the malignant cases is intriguing and needs further studies that can investigate its prognostic role.

Neurologic Conditions Associated with Cavus Foot Deformity

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Complete Excision of Intradural-Extraforaminal Spinal Tumors Using a Minimally Invasive 2-Incision Technique With Fixed Tubular Retractors

Spinal tumors are rare, of which intradural-extramedullary lesions form the majority of primary spinal tumors. Occasionally these may even be large, dumbbell shaped, with both intraspinal and extraspinal components. Complete gross total resection is the gold standard in the removal of these tumors since most are benign in nature. Traditionally this has been achieved using large open midline approaches that involve significant muscle dissection, extensive laminectomy, and even facetectomy. This may lead to instability, requiring stabilization to prevent deformity. Minimally invasive surgical approaches using fixed tubular retractors may obviate this need by minimizing the amount of muscle stripping and bony resection required for complete tumor excision. By utilizing facet sparing corridors, the authors describe a novel 2-incision minimally invasive surgical technique that combines a paramedian and a far-lateral approach to access both the intraspinal and extraforaminal, paraspinal portions of the tumor for achieving complete excision. Three illustrative cases are discussed with tumors in 2 different spinal locations that highlights the versatility of this technique-1 in the cervical region and the other 2 in the thoracolumbar region.

Long Completely Cystic Sciatic Schwannoma: A Rare Case

Schwannomas are the most common peripheral nerve sheath tumors. Benign schwannomas with malignant transformation are rarely reported. Most common schwannomas occur in the head and neck region. Sciatic schwannomas are rare, as are completely cystic schwannomas. Sciatic nerve schwannomas represent less than 1% of all schwannomas. Benign tumors in the sciatic nerve consist of 60% neurofibromas and 38% schwannomas. In general, a schwannoma induces chronic symptoms. It can be misleading, sometimes mimicking degenerative spinal pathology due to disc herniation. Schwannoma involving the sciatic nerve can be asymptomatic or may present with sciatica or neurological deficits. Most schwannomas are solid or heterogeneous tumors, and completely cystic schwannomas are rare. The differential diagnoses of nondiscogenic sciatica include lumbar disc herniation, tumor, abscess, hematoma, facet syndrome, lumbar instability, sacroiliitis, piriformis syndrome, and sciatic neuritis. We report a rare case of a long completely cystic sciatic schwannoma in the left foraminal L5–S1 zone extending to the left ischial groove with chronic sciatica that was diagnosed radiologically with a combination of conventional MRI and MR neurography and confirmed histopathologically by surgical resection. The patient previously had conservative therapy, but the complaints were not reduced. Nonsurgical therapy is considered the first choice, and surgical therapy is indicated in cases that do not respond to conservative therapy, with recurrent cysts, severe pain, or neurological deficits.

Single-Staged Management of Pediatric Neuropathic Scoliosis with Intradural-Extramedullary Schwannoma and Improvement in Intraoperative Neuromonitoring: A Case Report

CASE

A 16-year-old girl with lumbar prominence presented to our outpatient clinic complaining of sporadic back pain without paresthesia. Radiographic investigation revealed a 68° left thoracolumbar curve with the apex at L1. Preoperative magnetic resonance imaging identified a mass at T10-11, subsequently confirmed by pathology as a schwannoma. She was treated surgically with resection and posterior spinal fusion in a single-staged procedure under neuromonitoring guidance. Intraoperative improvement in motor evoked potentials after resection informed the decision to perform simultaneous deformity correction.

CONCLUSION

We discuss the unusual coincidence of a schwannoma with scoliosis and our management algorithm based on operative changes in neuromonitoring.

Management of Extramedullary Intradural Spinal Tumors: The Impact of Clinical Status, Intraoperative Neurophysiological Monitoring and Surgical Approach on Outcomes in a 12-Year Double-Center Experience

Objective: Intradural Extramedullary (IDEM) tumors are usually treated with surgical excision. The aim of this study was to investigate the impact on clinical outcomes of pre-surgical clinical conditions, intraoperative neurophysiological monitoring (IONM), surgical access to the spinal canal, histology, degree of resection and intra/postoperative complications.

Methods: This is a retrospective observational study analyzing data of patients suffering from IDEM tumors who underwent surgical treatment over a 12 year period in a double-center experience. Data were extracted from a prospectively maintained database and included: sex, age at diagnosis, clinical status according to the modified McCormick Scale (Grades I-V) at admission, discharge, and follow-up, tumor histology, type of surgical access to the spinal canal (bilateral laminectomy vs. monolateral laminectomy vs. laminoplasty), degree of surgical removal, use and type of IONM, occurrence and type of intraoperative complications, use of Ultrasonic Aspirator (CUSA), radiological follow-up.

Results: A total number of 249 patients was included with a mean follow-up of 48.3 months. Gross total resection was achieved in 210 patients (84.3%) mostly in Schwannomas (45.2%) and Meningiomas (40.4%). IONM was performed in 162 procedures (65%) and D-wave was recorded in 64.2% of all cervical and thoracic locations (99 patients). The linear regression diagram for McCormick grades before and after surgery (follow-up) showed a correlation between preoperative and postoperative clinical status. A statistically significant correlation was found between absence of worsening of clinical condition at follow-up and use of IONM at follow-up (p = 0.01) but not at discharge. No associations were found between the choice of surgical approach and the extent of resection (p = 0.79), the presence of recurrence or residual tumor (p = 0.14) or CSF leakage (p = 0.25). The extent of resection was not associated with the use of IONM (p = 0.91) or CUSA (p = 0.19).

Conclusion: A reliable prediction of clinical improvement could be made based on pre-operative clinical status. The use of IONM resulted in better clinical outcomes at follow-up (not at discharge), but no associations were found with the extent of resection. The use of minimally invasive approaches such as monolateral laminectomy showed to be effective and not associated with worse outcomes or increased complications.

Surgical management and outcome of adult posterior cranial fossa and spinal hemangioblastoma: a 6-case series and literature review

OBJECTIVE

Hemangioblastomas of the posterior cranial fossa and spinal cord in adults are excessively vascularized, well-differentiated, and scarce tumors with no metastatic potential. This paper discusses its surgical management and outcome, pointing out their morphological, radiological, and histopathological aspects. This report based on a personal series of six patients and on a literature review.

METHODS

A single-institution personal 6-case series of adult patients diagnosed and operated on by a senior neurosurgeon (KIA) due to posterior cranial fossa or spinal cord hemangioblastoma was analyzed. For easier understanding of hemangioblastoma, we have classified them into four different types.

RESULTS

The tumors, which were all surgically treated, were located in the posterior cranial fossa in five patients (4 cerebellar, 1 brain stem) and intramedullary in the thoracic spinal cord in one patient. All patients successfully recovered neurologically after a complete tumor resection, having no post-operative neurological deficit or other complications.

CONCLUSION

Surgical management of cerebellar and spinal cord hemangioblastoma in adults is highly dependent on its morphological features, as well as on microsurgical technique applied. Since huge differences exist between the cystic/nodular tumor type (Type 1) and the solid type and its two additional variants (Types 2-4), morphology is the most important consideration when deciding surgical approach. Despite significant morphological differences among different subtypes of hemangioblastomas, their histology appears to be relatively similar. Nonetheless, a meticulous and refined surgical technique has to be utilized to achieve a successful outcome.

Initial Report of an Intradural Extramedullary Metastasis of a Pancreatic Neuroendocrine Tumor to the Cervical Spine: A Case Report and Review of the Literature

BACKGROUND

Pancreatic neuroendocrine tumors (pNETs) are known to frequently metastasize to the liver and lymphatics; however, metastasis to the spine is exceedingly rare. We report the first case of an intradural, extramedullary pNET metastasis to the upper cervical spine.

CASE DESCRIPTION

A 75-year-old Hispanic male patient with history of stage IV pNET with metastasis to the liver and lymph nodes and new-onset lymphadenopathy seen on CT of the chest was found on positron emission tomography scan to have a lesion in the cervical spine. The patient was neurologically intact on physical examination, yet given the patient's medical history, magnetic resonance imaging of the cervical spine was performed, revealing a right-sided intradural, extramedullary mass at the C1-C2 level with associated mass effect on the spinal cord, likely representing a schwannoma. Due to the tumor size, mass effect, and the need for definitive tissue diagnosis, a partial C1-C2 laminectomy with intradural resection of the tumor was performed. The histology was consistent with the patient's known pNET.

CONCLUSIONS

As treatment for pNETs has evolved, there has been a surge in unique presentations of systemic well-differentiated pNETs being reported. It is vital that patients diagnosed with pNET be monitored for metastases, and when discovered, treated promptly.

Functional outcome in intradural extramedullary tumor patients: Case series

Introduction

Intradural extramedullary (IDEM) spinal cord tumors account two thirds of all intraspinal tumors. These tumors produce pain syndromes, a variety of neurological symptoms-motor, sensory, sphincter or a combination of thereof. Preferred treatment is microsurgical radical resection. The objective of this study was analyzed and discuss about functional outcome in IDEM.

Presentation of case

We present serial case of 15 patients, that consist of 8 males and 7 females, with the mean age of 43,4 years old, ranging from 16 to 82 years old. The outcomes were followed up with Karnofsky Score and Tomita to analyzed metastasis of the tumor. The mean of Karnofsky score in this study was 74 with no patient had metastatic intradural tumor, therefore the Tomita score in these patients is incalculable.

Discussion

MRI confirmed the location and extent of the tumor for definitive diagnosis. We then performed excision of the tumor or decompression of the spinal canal followed by posterior stabilization if needed. Minimal complaint regarding pain and/or numbness were found. Post operation functional outcome of the patient is monitored using Karnofsky score.

Conclusion

In all except one patient, the functional outcome of the patients is greater than 50 based on Karnofsky score. In this case series, the good functional outcome is due to all tumor were primary tumor which originate from the spine. Furthermore, all tumor had benign characteristic based on the anatomical pathology result. In consequence, gross total resection can be achieved thus resulting a good overall functional outcome of the patients.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Flipped Reposition Laminoplasty for Excision of Intradural Extramedullary Tumors in the Thoracolumbar Spine: A Case Series of 14 Patients

STUDY DESIGN

A retrospective study was done to assess the outcome of the new technique of flipped reposition laminoplasty for excision of intradural extramedullary (IDEM) spinal tumors of the thoracolumbar region.

PURPOSE

To describe flipped reposition laminoplasty technique and evaluate its outcomes.

OVERVIEW OF LITERATURE

Laminectomy has been the conventional approach for the surgical excision of IDEM spinal tumors, but it has potential postoperative complications. Laminoplasty maintains the posterior arch of the spine and avoids complications seen in Laminectomy, such as instability, epidural scarring, and kyphotic deformity.

METHODS

Fourteen patients (nine females and five males) diagnosed with IDEM tumors of the thoracolumbar region operated between 2016 and 2018 were included in this study. Pathologically, five cases were schwannomas; four cases were meningiomas; two cases were ependymomas; and one case each was lymphoma, neurofibroma, and teratoma. All patients had their neurological deficits documented using the American Spinal Injury Association (ASIA) impairment scale. After completion of all preanesthetic formalities, the patients were operated upon by a single surgeon using the flipped reposition laminoplasty technique. Follow-up was done at 1, 3, 6, and 12 months post operation and yearly thereafter.

RESULTS

The mean age of the patients was 35.28 years (14-65 years), and the mean follow-up duration was 17 months (6-26 months). Two patients were assessed with ASIA grade A neurology, one patient improved to ASIA grade B, whereas the other did not improve. Two patients improved from ASIA grade B to ASIA grade D, and seven patients with ASIA grades C and D improved to ASIA grade E. Fusion at the osteotomy site was seen in 92.85% (13 out of 14) cases on one side within 6 months post operation. Fusion was seen in all the cases within 1 year post operation.

CONCLUSIONS

Flipped reposition laminoplasty is an excellent technique providing adequate exposure and additional stability postoperatively.

Detecting the long non‑coding RNA signature related to spinal cord ependymal tumor subtype using a genome‑wide methylome analysis approach

Ependymoma is a type of intramedullary tumor that tends to occur in the adult spinal cord. Ependymoma affects the nervous system and has significant impacts on the quality of life, and it may lead to mortality. Previous studies have performed molecular classification of spinal cord ependymal tumors at the DNA methylation level. However, the DNA methylation status of non-coding regions in spinal cord ependymal tumors remains unclear. In the present study, a genome-wide methylome method was used to characterize the DNA methylation landscape of long non-coding RNAs (lncRNAs) in spinal cord ependymal tumor samples. The present study identified lncRNA signatures associated with tumor subtypes based on the methylation status of lncRNA promoters. The present results suggested that the identified lncRNA signatures were associated with cancer- or nervous system-related protein-coding genes. The majority of the identified lncRNAs was hypomethylated, and may have a role in spinal cord development. The present findings suggested that detection of tumor subtype-specific lncRNAs may facilitate the identification of novel diagnostic and therapeutic strategies to treat patients with spinal cord ependymal tumor.

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip

BACKGROUND

The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought.

OBJECTIVE

The purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI).

METHODS

We performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018.

RESULTS

The mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks.

CONCLUSIONS

We describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.

A rare case of an intramedullary metastasis of a myxopapillary ependymoma

Background:

Myxopapillary ependimoma (MPE) is a benign slow-growing tumor, and it has been designated histologically as a Grade I neoplasm according to the 2016 World Health Organization classification. Despite the benign character, dissemination and metastasis have occasionally been reported. The retrograde dissemination to other levels of the neuraxis is extremely rare, being more frequent to the intracranial compartment.

Case Description:

We hereby present a case of medullary metastasis of cauda equina MPE, with a history of having undergone a subtotal resection and postoperative adjuvant radiotherapy. The patient presents complaints of night dorsal pain attributable to intradural metastasis twenty-one years after the first surgical intervention.

Conclusion:

The case reported highlights the importance of long follow-up in patients with MPE, since the possibility of secondary seeding to distant craniospinal sites or local spinal sites after surgery, and radiotherapy should be considered in metastatic disease.

SPINAL DUMBBELL EPIDURAL HEMANGIOMA: TWO STAGE/SAME SITTING/SAME POSITION POSTERIOR MICROSURGICAL AND TRANSTHORACIC ENDOSCOPIC RESECTION - CASE REPORT AND REVIEW OF THE LITERATURE

SUMMARY – Spinal dumbbell tumors are defined by a narrowing at the point where they penetrate the intervertebral foramina or dura mater, assuming an hourglass or dumbbell shape. Dumbbell-shaped spinal hemangiomas are extremely rare. We describe a dumbbell spinal tumor (epidural cavernous hemangioma) resected by a 2-stage single-sitting combined approach. We also conduct a substantial literature review of the subject. We present a case of a 78-year-old male who was found to have a homogeneously enhancing, dumbbell-shaped, intraspinal, extradural tumor mass extending into the left chest cavity. The tumor was resected with a single-sitting 2-stage posterior technique: a microsurgical approach, followed by endoscopic resection via a thoracoscopic approach. There are several reports in the literature on the combined approach for dumbbell tumors of the spinal cord. Our case is the first to describe 2-stage combined surgery in 1 sitting for dumbbell hemangioma with the patient in the lateral decubitus position for the thoracoscopic part of the surgery; and the use of a fat pad, which was applied in the neuroforamen via the posterior route, as a marker for resection during the transthoracic procedure.

Microsurgical Resection of Spinal Cord Hemangioblastoma: 2-Dimensional Operative Video

This video demonstrates microsurgical resection of spinal cord hemangioblastoma. Hemangioblastomas are rare, benign, highly vascularized tumors classified as grade I according to World Health Organization classification systems. About 3% of all intramedullary tumors are hemangioblastomas.1,2 Spinal cord hemangioblastomas are either sporadic3,4 or manifestations of von Hippel-Lindau (VHL) disease in 20% to 45% of patients.5,6 A 30-year-old male presented with sudden onset urinary incontinence. Magnetic resonance imaging showed contrast enhancing intramedullary tumor with adjacent cyst in T11, and syringomyelia extending to C1. Surgical resection followed rules that apply to resection of arteriovascular malformations: coagulation of arterial feeders precedes the coagulation of the draining vein, which is preserved until the end of surgery.2,4,5,7,8 First, posterior midline myelotomy was performed and the tumor cyst was drained in order to develop a dissection plane. Following this, we continuously separated dorsal nerve roots from the tumor nodule using microsurgical technique. The key step in tumor resection is devascularization of the tumor, achievable in 2 ways.2,7,9-13 The circumferential detachment of the normal pia from the tumor pia is crucial in developing a plane of dissection. The coagulation and division of arterial feeders while preserving the drainage vein further devascularizes the tumor. Once the tumor mural nodule was detached from the spinal cord, the drainage vein was coagulated last and the tumor was removed. The patient fully recovered from his incontinence and was neurologically intact. Screening for VHL disease was negative. Written consent was obtained directly from the patient.

Awake Intradural Spinal Tumor Resection; Case Report and Literature Review

BACKGROUND

Meningioma is a common slow-growing spinal tumor with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anesthesia. However, there exist high-anesthetic-risk patients unsuitable for general anesthesia. Performing spinal surgeries under local anesthesia and sedation has been reported, albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies.

CASE DESCRIPTION

We report a 63-year-old woman with critical aortic stenosis, coronary artery disease, and severe chronic obstructive airways disease who presented with 10 months' history of worsening back pain and bilateral leg pain, ataxia, hyperreflexia in lower limbs, as well as altered lower limb sensation. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was American Society of Anesthesiologists class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumor under local anesthesia and sedation with no significant complications and clinical improvement.

CONCLUSION

Our illustrative case and literature review suggest that using local anesthesia and sedation to perform spinal surgeries including intradural tumors is possible even in high-risk patients with good outcome. Our American Society of Anesthesiologists class IV patient tolerated the surgery well with gross total tumor resection and subsequent resolution of the symptoms.

CSF-Related Complications After Intradural Spinal Tumor Surgery: Utility of an Autologous Fat Graft

Object:

The incidence of cerebrospinal fluid (CSF)-related complications after intradural spinal tumor (IST) surgery is high and reported in up to 18% of patients. However, no efficient way to prevent those complications has been reported so far. Treating these complications may require prolonged bed rest, re-exploration, external lumbar drain, use of antibiotics, and possible precipitation of other complications. To alleviate the risk of CSF-related complications, we prospectively adopted the intraoperative use of autologous fat grafting after IST surgery.

Methods:

This is a perspective analysis of 37 cases (out of 40 cases series) that a prospective use of abdominal fat autograft was applied during dural closure. After the tumor was resected and the dura closed, we used the Valsalva maneuver to ensure watertight closure. CSF leak was prevented with the enforcement of suture with a fat autograft as necessary. In addition a thin layer of fat tissue was then placed over the dura to obliterate any dead space. Fibrin glue was then applied over the graft. Filling the dead space with the fat graft prevented a low-pressure space in which CSF could pool and form a pseudomeningocele.

Results:

After adopting the fat autograft technique, we did not observe any post-surgery CSF-related complications in any of these patients.

Conclusions:

The prospective use of autologous fat grafting can ensure watertight dural closure and obliterate the dead space created during surgical exposure and bone removal. This technique significantly reduces, and may completely eliminate, postoperative CSF-related complications in patients with ISTs.

Surgically Treated Primary Spinal Cord Neoplasms in Southeastern Nigeria

Background:

Primary spinal cord tumors are not as frequently encountered as their cranial counterparts. They could present in such an indolent manner that requires a reasonable index of suspicion for their diagnosis to be considered.

Objective:

The objective of this study is to analyze the incidence and pattern of primary spinal cord and appendage neoplasms in patients surgically treated in our institution over a decade of practice.

Materials and Methods:

A retrospective review of clinical, radiological, and histopathology profiles of patients surgically treated for primary spinal cord tumor from 2006 to 2016 was carried out. Retrieved data were analyzed using SPSS version 21.

Results:

Out of 472 spine procedures were performed within the study period 17 (3.6%) cases of histologically proven primary spinal cord tumors were identified. The age of patients ranged between 17 and 77 years with a mean age was 45 years. The male: female ratio was 1:1.1. Motor deficit and pain were the most common presenting symptoms seen in 35.3% and 29.4% of patients, respectively. Meningiomas are the most common histological diagnosis (70.6%), distantly followed by Schwannoma (17.6%). The most common location of the tumors was intradural extramedullary (70.6%). All patients had gross total resection of tumor with no perioperative mortality.

Conclusion:

Meningioma is the most common surgically treated primary spinal cord tumor in our setting. Surgery is associated with good outcome.

Keyhole approaches to intradural pathologies

OBJECTIVE

Spinal tumors account for 2%–4% of all tumors of the central nervous system and can be intramedullary, intradural extramedullary, or extradural. In the past, wide approaches were used to obtain safe access to these tumors, as complete resection is the goal in treating most tumor entities. To reduce surgical complications due to large skin incisions and destabilizing laminectomies, minimally invasive approaches were established. In this study, the authors share their experience with mini-open approaches to intradural tumor pathologies.

METHODS

The authors retrospectively reviewed cases involving patients with intramedullary and intradural extramedullary lesions treated between 2009 and 2016. They present their surgical mini-open approach to the spinal cord as well as unique characteristics, key steps, and postsurgical complications for specific tumor subgroups (meningioma, neuroma, and intramedullary tumors).

RESULTS

A total of 245 intradural tumors were surgically treated during the study period. Of these lesions, 151 were intradural extramedullary meningiomas (n = 79) or neuromas (n = 72). Nine (12.5%) of the neuromas were dumbbell neuromas. Ninety-four tumors were intramedullary. The mean age of the patients was 51.4 years, and 53.9% were female. The mean duration of follow-up was 46.0 months.

All meningiomas and neuromas could be resected using a mini-open keyhole approach, but only 5.3% of the intramedullary lesions could be accessed using this technique. Of the 94 patients with intramedullary tumors, 76.6% required a laminotomy, 7.4% required a hemilaminectomy, and 10.6% required a 2-level laminectomy. Only 2 of the patients with intramedullary tumors needed stabilization for progressive cervical kyphosis during follow-up. None of the other patients developed spinal instability after undergoing surgery via the mini-open (keyhole/interlaminar) approach. There were significantly more surgery-associated complications in the large exposure group than in the patients treated with the mini-open approach (19.1% vs 9.6%, p < 0.01).

CONCLUSIONS

Intradural extramedullary and in selected cases intramedullary pathologies may safely be resected using a mini-open interlaminar approach. Avoiding laminectomy, laminotomy, and even hemilaminectomy preserves spinal stability and significantly reduces comorbidities, while still allowing for complete resection of these tumors.

[Clinical Features of Intradural Extramedullary Spinal Cord Metastases in Primary Lung Cancer]

背景与目的

肺癌硬膜下脊髓外转移罕见, 可导致严重的神经损害, 本研究旨在阐明其临床特征。

方法

2013年5月-2016年5月, 北京协和医院8例确诊硬膜下脊髓外转移肺癌患者纳入该研究, 系统回顾分析临床资料。

结果

7例非小细胞肺癌及1例小细胞肺癌合并硬膜下脊髓外转移。马尾综合征是最常见的临床表现。行腰椎穿刺的5例(100%)患者脑脊液找到肿瘤细胞。脊髓增强核磁(magnetic resonance imaging, MRI)发现, 3例软脊膜弥漫线样增强, 4例硬膜下脊髓外多发结节, 1例具有上述两种表现。4例接受靶向治疗和/或放疗患者神经系统症状改善或稳定。中位生存时间是5.8个月。

结论

硬膜下脊髓外转移需依靠神经系统症状及增强MRI影像学检查诊断。靶向治疗和/或放疗可能有效。

Primary Seeding of Myxopapillary Ependymoma: Different Disease in Adult Population? Case Report and Review of Literature

Myxopapillary ependymoma (MPE) is a slow-growing tumor, occurring most often in adults. It originates from the filum terminale in the area of the conus medullaris and cauda equina and is considered a benign lesion. Despite this classification, however, recurrence after both partial and gross total resection is well known. In the pediatric population, primary MPE seeding and generally more aggressive clinical course is well documented and treated through gross total resection, if possible, followed by irradiation. In adults, however, primary MPE seeding is rarely seen. There are few prior reports describing primary metastases into multiple spinal locations in an adult before resection of an MPE. The reason for this difference among pediatric and adult MPE remains unclear. We present the case of a 32-year-old man with primary seeding of an MPE into multiple lumbosacral areas. The patient underwent gross total resection of the lesions and had an uneventful postoperative course. Primary seeding could be a sign of aggressive behavior in this tumor. Complete craniospinal magnetic resonance imaging studies should be done before and after surgery in patients who present with a multifocal primary MPE. Furthermore, patients with a history of primary tumor seeding of MPE should be thoroughly evaluated radiologically. Unlike in pediatric populations, the need for postoperative irradiation in adults is less clear and further studies-particularly genetic ones-are warranted.

Thoracic exophytic ependymoma masquerading as a benign extra-axial tumor

Spinal tumors are conventionally differentiated based on location in relation to the spinal cord. Benign spinal tumors such as schwannomas and meningiomas are typically extra-axial (intradural extramedullary) lesions, whereas more aggressive primary spinal tumors such as ependymomas are typically intramedullary masses. Rarely, ependymomas can have both intramedullary and extramedullary components (typically referred to as exophytic ependymomas). We report a case of a spinal exophytic ependymoma that radiographically masqueraded as a benign intradural extramedullary lesion causing cord compression and neurologic deficit in a 47-year-old man. The diagnosis of exophytic ependymoma was made intra-operatively, with resultant gross total resection of the extramedullary portion and subtotal resection of the intramedullary portion. Histopathological examination confirmed ependymoma with World Health Organization grade II/IV. Pre-operative suspicion of an exophytic ependymoma influences operative planning and clinical management. We review the literature and discuss clinical management strategies for these interesting spinal tumors.

Minimally invasive removal of lumbar intradural extramedullary lesions using the interlaminar approach

OBJECT Posterior midline laminectomy or hemilaminectomy has been successfully applied as the standard microsurgical technique for the treatment of spinal intradural pathologies. However, the associated risks of postoperative spinal instability increase the need for subsequent fusion surgery to prevent potential long-term spinal deformity. Continuous efforts have been made to minimize injuries to the surrounding tissue resulting from surgical manipulations. The authors report here their experiences with a novel minimally invasive surgical approach, namely the interlaminar approach, for the treatment of lumbar intraspinal tumors. METHODS A retrospective review was conducted of patients at the Second Affiliated Hospital of Zhejiang University School of Medicine who underwent minimally invasive resection of lumbar intradural-extramedullary tumors. By using an operative microscope, in addition to an endoscope when necessary, the authors were able to treat all patients with a unilateral, paramedian, bone-sparing interlaminar technique. Data including preoperative neurological status, tumor location, size, pathological diagnosis, extension of resections, intraoperative blood loss, length of hospital stay, and clinical outcomes were obtained through clinical and radiological examinations. RESULTS Eighteen patients diagnosed with lumbar intradural-extramedullary tumors were treated from October 2013 to March 2015 by this interlaminar technique. A microscope was used in 15 cases, and the remaining 3 cases were treated using a microscope as well as an endoscope. There were 14 schwannomas, 2 ependymomas, 1 epidermoid cyst, and 1 enterogenous cyst. Postoperative radiological follow-up revealed complete removal of all the lesions and no signs of bone defects in the lamina. At clinical follow-up, 14 of the 18 patients had less pain, and patients' motor/sensory functions improved or remained normal in all cases except 1. CONClUSIONS When meeting certain selection criteria, intradural-extramedullary lumbar tumors, especially schwannomas, can be completely and safely resected through a less-invasive interlaminar approach using a microscope, or a microscope in addition to an endoscope when necessary. This approach was advantageous because it caused even less bone destruction, resulting in better postoperative spinal stability, no need for facetectomy and fusion, and quicker functional recovery for the patients. Individualized surgical planning according to preoperative radiological findings is key to a successful microsurgical resection of these lesions through the interlaminar space.

Neuroimaging of spine tumors

Intramedullary, intradural/extramedullary, and extradural spine tumors comprise a wide range of neoplasms with an even wider range of clinical symptoms and prognostic features. Magnetic resonance imaging (MRI), commonly used to evaluate the spine in patients presenting with pain, can further characterize lesions that may be encountered on other imaging studies, such as bone scintigraphy or computed tomography (CT). The advantage of the MRI is its multiplane capabilities, superior contrast agent resolution, and flexible protocols that play an important role in assessing tumor location, extent in directing biopsy, in planning proper therapy, and in evaluating therapeutic results. A multimodality approach can be used to fully characterize the lesion and the combination of information obtained from the different modalities usually narrows the diagnostic possibilities significantly. The diagnosis of spinal tumors is based on patient age, topographic features of the tumor, and lesion pattern, as seen at CT and MRI. The shift to high-end imaging incorporating diffusion-weighted imaging, diffusion tensor imaging, magnetic resonance spectroscopy, whole-body short tau inversion recovery, positron emission tomography, intraoperative and high-field MRI as part of the mainstream clinical imaging protocol has provided neurologists, neuro-oncologists, and neurosurgeons a window of opportunity to assess the biologic behavior of spine neoplasms. This chapter reviews neuroimaging of spine tumors, primary and secondary, discussing routine and newer modalities that can reduce the significant morbidity associated with these neoplasms.

Meningeal relationships to the spinal nerves and rootlets: a gross, histological, and radiological study with application to intradural extramedullary spinal tumors

INTRODUCTION

Juxtapositional tumors of the spinal nerve roots have been noted to not only interact with the roots at various vertebral levels, but also differ among patients. Therefore, the aim of the current study was to elucidate the potential for variation among the relationships of the meningeal layers at different nerve levels.

METHODS

In 20 unembalmed adult cadavers and five fetal specimens, the spinal nerve roots from the cervical, thoracic, and lumbar regions were harvested with their associated meningeal layers and subjected to microdissection, histological analysis, or radiological imaging using 9.4-T MRI.

RESULTS

As the nerve rootlets passed from the cord, they received their root sheath covering from the pia. After crossing the subarachnoid space to reach the apertures in the dura, they received two additional looser sheaths, an outer from the dura and an inner from the arachnoid. The pia mater always ended proximal to the arachnoid, and the pia and arachnoid layers extended more distally along the roots with caudal descent. Although the dorsal and ventral roots generally exited through separate dural openings, a single dural opening was also observed, often in the lower spinal regions. Thin intradural septations almost always separated the dorsal and ventral rootlets. The left and right sides frequently differed within individuals.

CONCLUSIONS

On the basis of our study, variations of the meninges surrounding the spinal nerve roots are common, but themes do exist. Such data support surgical observations of the different interactions between tumors in these regions with surrounding neural tissues.

Surgery of Intradural Extramedullary Tumors

BACKGROUND:

Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits.

OBJECTIVE:

To evaluate the effects of surgery for IDEMTs.

METHODS:

This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software.

RESULTS:

One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of −2.400 (P &lt; .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ2 = 27.6; P &lt; .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4).

CONCLUSION:

Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.

Spinal ependymomas: benefits of extent of resection for different histological grades

Although the World Health Organization (WHO) categorizes spinal ependymomas into three histological grades, difference in surgical outcomes between WHO grades I and II tumors are unclear. For these benign tumors, prognosis may be best determined by factors other than tumor grade alone, such as extent of resection. To analyze the effects of the extent of resection on different grades of spinal ependymomas, we performed a comprehensive literature review to identify adult spinal ependymoma patients who received surgical resection with a clearly identifiable WHO grade. A total of 175 patients were identified. While grade III tumors carried the worst prognosis as expected (p<0.001), grade I and II tumors did not differ significantly in outcomes following surgery. Overall, gross total resection (GTR, 68.7%, 114/166) provided significantly improved progression-free survival (PFS, p<0.001) and overall survival (OS, p=0.022) compared to the subtotal resection group. Surprisingly, the highest GTR rate was achieved for grade II tumors (78.8%, 78/99; p<0.001) followed by grade I (58.9%, 33/56) and grade III tumors (27.3%, 3/11). Interestingly, PFS was significantly improved by GTR for grade II tumors (p<0.001), but not for grade I (p=0.705). Similar trends, although not statistically significant, were found for OS. Our results show that while GTR provides the best overall outcomes, GTR is most effective for classic grade II ependymomas, but not for grade I ependymomas. Despite having a lower WHO grade, myxopapillary ependymomas have a lower GTR rate, and benefit less from GTR.

Myxopapillary ependymoma as a cause of back pain in a young male - A case report

OBJECTIVE

Primary spinal cord tumours are rare causes of low back pain but can be a significant cause of morbidity if undiagnosed and untreated. The following is a case of a young male patient presenting with low back pain and radicular symptoms caused by myxopapillary ependymoma.

CLINICAL FEATURES

A nineteen year old male presented to an orthopaedic surgeon with a long history of back pain. He was initially diagnosed with soft tissue injuries and discharged. He began to experience erectile and bowel dysfunction two years later and was re-referred to the orthopaedic surgeon by his family physician but was lost to follow-up. The patient did not present to the surgeon until two years after his symptom profile changed. At that point, MRI examinations revealed a large myxopapillary ependymoma extending from T12 to L4 that was confirmed by a pathologist.

INTERVENTION AND OUTCOME

The tumour was surgically resected with subsequent adjuvant radiotherapy. After one year, the patient required continued catheterization and had poor anal tone. His back and leg complaints were almost normal. Follow-up MRI examinations revealed no disease progression or new spinal lesions at 4 years after the initial diagnosis.

CONCLUSION

The clinical presentation of primary spinal cord tumours is non-specific and can easily be missed. In cases of chronic back pain, signs and symptoms should be regularly monitored for changes indicative of progressive neurological compromise such as sensory, motor and bowel/bladder dysfunction. If there is deterioration of clinical signs and symptoms, a spinal tumour should be considered in the list of differential diagnoses. Delayed diagnosis and treatment of these rare causes of back pain could lead to poor outcomes; therefore, a referral to a surgeon should be done immediately with proper follow up to ensure continuity of care.

Prognosis by tumor location in adults with spinal ependymomas

OBJECT

Ependymomas are primary central nervous system tumors that occur more frequently in the spines of adults than they do there in children. Previous studies consist mainly of retrospective single-institutional experiences or case studies. In this study, a comprehensive literature review was performed on reported cases of spinal ependymoma treated with resection to determine whether tumor location along the spinal axis conveys important prognostic information.

METHODS

A PubMed search was performed to identify all papers that included data on patients with spinal ependymoma. Only cases involving adult patients who underwent ependymoma resection with a clearly reported tumor location were included for analysis. Tumor locations were separated into 6 groups: cervicomedullary, cervical, cervicothoracic, thoracic, thoracolumbar, and conus + cauda equina. Kaplan-Meier survival and Cox regression analyses were performed to determine the effect of tumor location on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 447 patients who underwent resection of spinal ependymomas with clearly indicated location of tumor were identified. The most common locations of spinal ependymomas were the cervical (32.0%) and conus + cauda equina (26.8%) regions. The thoracolumbar and cervicomedullary regions had the fewest tumors (accounting for, respectively, 5.1% and 3.4% of the total number of cases). The conus + cauda equina and thoracolumbar regions had the highest percentage of WHO Grade I tumors, while tumors located above these regions consisted of mostly WHO Grade II tumors. Despite the tendency for benign grades in the lower spinal regions, PFS for patients with spinal ependymomas in the lower 3 regions (thoracic, thoracolumbar, conus + cauda equina) was significantly shorter (p < 0.001) than for those with tumors in the upper regions (cervicomedullary, cervical, cervicothoracic), but the difference in OS did not achieve statistical significance (p = 0.131).

CONCLUSIONS

Spinal ependymomas along different regions of spinal axis have different characteristics and clinical behaviors. Tumor grade, extent of resection, and PFS varied by tumor location (upper vs lower spinal regions), while OS did not. Recurrence rates were higher for the lower spinal cord tumors, despite a greater prevalence of lower WHO grade lesions, compared with upper spinal cord tumors, suggesting that tumor location along the spinal axis is an important prognostic factor.